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Astarté Client Intake Form

Please fill out the following form. Your answers are strictly confidential and will not be shared with anyone. Your information is important for the safety and efficacy of your services. Anything with an "*" is required. You may also chose to discuss anything at the time of services but we please ask that you fill out as much as you can, sign, and return prior to your first service. Thank you.

Date of birth
Month
Day
Year
Do you have any of the following conditions? If yes, please select them:
Skin Condition
How does your skin heal?
Do you have any known allergies?
Yes
No
Do you consume alcohol?
Yes
No
Are you pregnant?
Yes
No
Are you trying or planning to be pregnant?
Yes
No
Are you taking any contraceptive pills?
Yes
No
Are you breastfeeding?
Yes
No
Do you consume caffeinated drinks?
Yes
No
Do you wear contact lenses?
Yes
No
Are you currently on any kind of diet?
Yes
No
Have you undergone any surgeries?
Yes
No

Terms & Conditions

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. 

I confirm that all information in this form is true and accurate.

I confirm that if I withhold some important information and complications happen, the clinic will not be liable.

I release this clinic and hold it harmless against any claims, expenses, damages, and liabilities.

Date Signed
Month
Day
Year
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