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Skin Health Form

Please fill out this confidential skin health form prior to your holistic skin consultation. It is important for your skin therapist to gather information including your medical history, skin concerns & symptoms, as well as diet & lifestyle, as these factors can have an impact on the overall health of your skin. This will help your skin therapist ensure that your progress is personalized and long lasting.
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  • Your Health


    Please advise us of any health problems you have or have had? This will help us with any health conditions that may be a contraindication to your treatment. For example, Autoimmune disease, cold sores, epilepsy, etc.

  • Product and Treatment History

  • Your Skin

  • General

  • Daily eating habits

  • Beverages

  • Digestion

  • Stress

  • Sleep

  • Women Only

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