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Aesthetics Consultation Form

Client Information

Date of Birth
Day
Month
Year
Multi-line address

Medical History

Are you currently under the care of a physician?
Yes
No
Do you have any of the following medical conditions?
Are you currently taking any medication, supplements, or herbal remedies?
Yes
No

Lifestyle and Habits

Do you smoke or use nicotine products?
Yes
No
Do you consume alcohol?
Yes
No
Do you regularly use suncreen?
Yes
No

Skin Analysis and Concerns

What concerns would you like to address? (Check all that apply)
Have you ever had any of the following treatments?

Consent and Acknowledgement

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Date
Day
Month
Year
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Day
Month
Year
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