Home · Client Intake

New Client Intake

Fill this out before your appointment — contact info, medical history, and consent, all on file when you walk in.

Step 1 of 5 — Contact Info

First Name

Last Name

Birthday

Address

City

State

Zip

Phone Email Emergency Contact Name Emergency Contact Number How did you hear about us?

What areas are to be treated?

A few quick yes/no questions

Have you ever been on Accutane?

Hormonal problem you've been treated for?

Chemical peel or scars in treatment area?

Medications that make you sensitive to light?

Medications / herbal supplements / topical creams you use Any allergies?

How often do you remove your hair?

Current hair removal methods (tap all that apply)

When was your last treatment?

Skin Type (provider will confirm)

The Fitzpatrick Scale

Not sure? Find the closest match above — your provider will confirm it at your visit.

I consent to clinical before/after photos being taken and stored in my file for treatment tracking.

We run specials throughout the year, including birthday offers, promotions, gift certificates, and discounts.

May we send you birthday specials, promotions, gift certificates, and discounts by text and/or email? * Required

Are you 18 or over? * Required

Type your name below as your signature.

Client Signature (type full name)

You're all set. We'll have this on file for your appointment.

Contact

The Laser Hair Removal & Personalized Skin Care in Babylon

Location