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Holistic SkincareShrii Aesthetics

Client Intake

Welcome to Shrii Aesthetics

Please complete this form to help us understand your skin concerns and provide the best care.

Personal Information

Tell us about yourself.

Emergency Contact

In case we need to reach someone during your visit.

How did you hear about us?

Skin Concerns

Select all that apply.

Medical History

Please answer the following questions.

Are you currently pregnant or nursing?

Do you have any allergies (food, medication, topical)?

Are you using Retin-A, Renova, or Accutane?

Have you had any chemical peels, microdermabrasion, or laser treatments in the past 6 months?

Do you have any medical conditions we should be aware of?

Are you currently taking any medications?

Do you have a history of cold sores or fever blisters?

Have you had any recent facial surgery or injections?

Current Skincare Routine

List the products you use regularly.

Lifestyle

Help us understand your daily habits.

Alcohol consumption

Exercise frequency

Stress level

Consent

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