Cosmetic Intake Form

Please correct the errors described below.

**Would you be interested in receiving emails on any upcoming cosmetic promotions and specials?

We offer many aesthetic services, products, and procedures. If you would like more information, please check the box of all that you are interested in:

Which of the following best describes your skin type and natural hair color?

Medical History

Autoimmune and neurologic diseases: (please check all that apply)

Are you allergic to any of the following products/ medications?

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