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A Touch of Woo
Clinton, MD
First and last name
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Date:
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Birthday
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November 2026
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Mobile number
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Please enter a phone number.
Email address
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Street address
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Apt, suite, etc. (optional)
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City
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State
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ZIP code
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Preferred Pronoun
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required
She/Her/Hers
He/Him/Hims
They/Them/Theirs
Other
Emergency Contact:
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Emergency Contact's Phone number:
*
Please enter a phone number.
Have you been under the care of a physician, dermatologist or other medical professional within the past year?
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required
Yes
No
If yes, explain:
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Have you had any of these health conditions in the past or present?
*
required
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart Problem
Varicose Veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure disorder
Fever blisters
Headaches (chronic)
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
Metal bone pins or plates
Phlebitis
blood clots
poor circulation
Blood clotting abnormalities
Psychological treatment
Insomnia
Keloid scarring
Skin disease/skin lesions
Any active infection
None of these
List any medications you take regularly:
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Do you have any metal implants or wear a pacemaker?
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required
Yes
No
Occupation
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Does your job require that you work outdoors?
*
required
Yes
No
Which of the following best describes your skin type? (Please check one)
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required
Type I Fair skin tones—Always burns, never tans
Type II Light skin tones—Burns easily, tans slightly
Type III Fair to olive skin tones—Burns moderately, tans moderately
Type IV Light brown skin tones—Burns slightly, tans easily
Type V Dark brown skin tones—Rarely burns, tans easily
Type VI Dark brown to black skin tones—Never burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?
*
required
Yes
No
If yes, please specify
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How many glasses of water do you drink per day? (Please check one)
*
required
<1 glass
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one)
*
required
None
1-2 drinks
3-5 drinks
6+ drinks
How many hours do you typically sleep each night?
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required
<3 hours
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
*
required
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
Are you taking oral contraceptives? (female clients only)
Yes
No
If yes, specify (female clients only)
Please fill out this field.
Are you pregnant or trying to become pregnant? (female clients only)
Yes
No
Are you lactating? (female clients only)
Yes
No
Any menopause problems? (female clients only)
Yes
No
If yes, please be specific: (female clients only)
Please fill out this field.
Do you experience irritation from shaving?
Yes
No
May I Call/Text you at the provided phone number to confirm future appointments?
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required
Yes
No
May I contact you via mail/email about future promotions and news?
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required
Yes
No
I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history.
*
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I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
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All appointment sales are final, and deposits are non-refundable. Cancellations or Rescheduling must be made at least 24 hours in advance, otherwise deposits will be forfeited.
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required
By Booking an appointment i acknowledge and agree to the no-refunds policy