Intake Form

Full Name*

Email*

Phone*

Date of Birth*

What is your reason for visit today? ex, HydraFacial,Facial, MLD, Waxing, etc,.*

Do you have any current medical conditions? Answer Yes / No. If YES, Please list:*

Are you taking any medication? Please answer Yes / No. If YES, Please list:*

Topical medication? Please answer Yes / No. If YES, Please list:*

Please list all surgeries, including cosmetic and date:*

Please list any allergies or allergic reactions:*

Please list any major accidents, injury and date:*

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10090 Pasadena Avenue B2 Cupertino CA