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Client Questionnaire

Please indicate if you have used any of the medications or drugs listed below in the last 2 years

Medications or Drugs
Medications or Drugs
Medical History (Please check all that applies)

Lifestyle Considerations

Have you ever had any reactions to any products or anything you have put on your face?
Please check any of these you are allergic to
Do you smoke/vape
Do you use fabric softner or fabric softer sheets in the dryer?
Do you swim in a chlorinated pool?
Do you work around tars, oils, grease, or inks?
Do you work overnight?
Are you currently under alot of stress?

(Common stress triggers: job loss, new job, wedding, death in family, divorce, school, heavy schedules

Do you use birth control pills, shots, or IUD?
Are you pregnant or nursing?
Do you have shaving irritation on the face?
DIET: Do you consume any of the following? Check all that applies
PRODUCTS CURRENTLY USING: Check all that applies
TREATMENTS: Have you recieved any skin treatments within the last 90 days?

For Virtual consultations only please upload minimum 3 quality photos showing (front, left, right) views of your face in natural lighting. 

Upload File
Upload File
Upload File

Client Photography Consent

We utilize all client photography for promotional materials, social media, website content, or related marketing purposes. You are NOT required to agree to photography. 

Do you consent to photography?

Thanks for submitting!
We’ll get back to you soon.

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