Surveypoint

Microdermabrasion Client Intake Form -Form Fill

Section One

Name

First Name

Name

Last Name

Email

Phone Number

Birthdate

Date

Address

Street Address

Address

Street Address Line 2

Address

City

Address

State / Province

Q10

Address

Postal / Zip Code

Q11

How many problems do you have?

Q12

How sensitive skin do you have?

Q13

How many of the following have you experienced before?

Q14

How much sun exposure do you get per day?

Q15

Are you pregnant or lactating?

Yes

Q16

Do you have any allergies? If yes, please list them.

Q17

What do you expect from this treatment?

Q18

Microdermabrasion Client Intake Form -Form Fill

Name

Name

Email

Phone Number

Birthdate

Address

Address

Address

Address

Address

How many problems do you have?

How sensitive skin do you have?

How many of the following have you experienced before?

How much sun exposure do you get per day?

Are you pregnant or lactating?

Do you have any allergies? If yes, please list them.

What do you expect from this treatment?

Client's Signature