Client Intake Form

Please fill out the information below accurately to ensure we can provide the best care tailored to your needs.

Click here if you would prefer to print the form.

    Name:
    Date of Birth:
    Phone Number:
    Email:

    Light Therapy Consultation

    Please indicate if any of the following apply to you:

    Sculptural Facelifting Massage Information

    Please provide information on any recent treatments you’ve received.

    Botox (How recent?):
    Threads (How recent?):
    Fillers (How recent?):
    Facelift (How recent?):

    Have you had any of the following treatments in the last month?

    List any prescription creams or oral medications provided by a dermatologist:

    Health Information

    Check all that apply: