top of page
Log In
Intake form for returning clients
Date picker
First name
Last name
Email
Any changes to your allergy list from the last visit?
*
No
Yes
If yes, please please list otherwise put "n/a"
Any use of topical or oral retinol products, or any medications that can cause your skin to be sensitive within the past 2 weeks?
No
Yes
Any changes to your health since the last visit?
No
Yes
If yes, please provide a brief explaination. Otherwise put "n/a"
By signing below, I hereby release L Egance Esthetics Wellness and Beauty harmless from and waive on behalf of myself, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Submit
bottom of page
