Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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(###)
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Referred by
Emergency Contact
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Emergency Contact Phone
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(###)
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What are your areas of concern?
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What do you like about your skin?
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What is your favorite part of a facial?
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Describe your skin right now. Please share as much detail as you can about the texture, feeling, and anything you’d like me to know about your skin.
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What would you like to achieve from your skin treatment today?
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What are your long-term skin goals?
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Are you pregnant or breastfeeding?
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Are you presently using (or have you used in the past) Accutane, Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids?
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Have you had Botox, Restylane, or other injections in the past 6 months?
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Are you presently under a physician's care for any skin conditions or other medical conditions?
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Please list any allergies below. Note that some products contain nut seed oils. I will adjust products used in the treatment room based on information you provide.
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Have you ever had a reaction to a skincare product before, such as spf, essential oils, or cosmetics, and if so how would you describe your skin’s reaction?
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I am going to be touching your face, arms, neck, and feet during your treatment. Are there any areas we should avoid?
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Choose one of the following that best describes you.
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Do you have a general budget in mind for facials and skincare products? This is a no-pressure, judgment-free space—I’m here to help you create a plan that feels supportive, sustainable, and aligned with your needs.
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Please list anything else you'd like me to know or understand about you.
How did you hear about us?
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Referred by a friend
Google or other web search
Instagram
Wild Hearts Wellness Client
Other
I have completed the New Client Intake form accurately and honestly, understanding that certain medications and conditions may impact my treatment. If I have any questions, I will address them with my esthetician before services. I understand the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes and not diagnostically prescriptive in nature. I give permission to the esthetician to perform facial services and will not hold Marma Holistic LLC accountable for any liability that may result from this treatment. I understand the information herein is to aid the therapist in providing better service and is confidential. I agree to inform my therapist of any changes to the information provided.
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