New Client Consultation Form

First Name *
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Last Name *
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Email *
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Street Address *
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City *
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Postal Code *
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Home Phone *
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Work Phone *
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Mobile Phone *
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Occupation *
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Birth Date (mm/dd/yy) *
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How did you hear about us? *
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Lifestyle

Are you pregnant? *
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Do you follow a restricted diet? *
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Do you exercise regularly? *
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Do you smoke? *
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Main Skincare Concerns

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Details
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Medical History

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Notes to Medical History
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Please list current medications
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Do you have any other medical condition that we should be aware of?
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Please list all known allergies
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I understand that it is my responsibility to inform Le Petit Spa of any changes to the information I have provided above.

This information will be kept confidential. We require your signature to keep your personal, treatment, and sales information on file. Thank you!

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