NEW CLIENT INTAKE FORM IF you are a new client to Me2Beauty please fill out the form below Name *FirstLastAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States of AmericaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountryEmail *Phone *Referred by:Reason for visit: *Medications:Have you had a facial before? If yes, how long ago?Have you had any chemical peels? If yes, how long ago?What other facial services/treatment have you had?Allergies?Do you take any supplements, herbs, or vitamins? Please specify.Have you been exposed to any tanning method in the past 24 hours?YesNoDo you smoke?YesNoDo you get sore/fever blisters?YesNoAre you pregnant or trying to get pregnant?YesNoAre you epileptic or suffer from seizure, have any metal implants, or pacemaker?YesNoDescribe your skinNormalOilyDry T-Zone CombinationFreckled Sun Damaged Uneven/BlotchyMature WrinkledSaggyFirm Large PoresAcne MiliaBlackheadBreakoutsScarredCysticMelasmaRosaceaCongested Hyperpigmentated SensitiveIrritated Tans Easily Burns EasilyAgreement *I agreeBy checking this box I fully understand all of the questions above and have answered them correctly and honestly. Furthermore, I know that it is my responsibility to alert the technician, upon every visit, about recent medical or physical conditions that have occurred. Without the above disclosure, I understand that the attending technician cannot optimize the effectiveness of any treatments or therapies. By checking this box, I consent to all procedures and treatments done at this facility and do not hold the technician or facility responsible for any complications incurred during any treatments and procedures today or in the future.Cancellation Policy *I agreeBy checking this box I agree to the following cancellation policy: In the even you must cancel or reschedule an appointment, please allow 24 hours. No shows will be charged in full. Late arrivals will receive the best possible service in the remainder of their allotted time. CommentSubmit