Patient Intake Form - Divina Skin & Body Boutique

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Gender

Current Medications or Supplements

Known Allergies *

Medical Conditions (Check all that apply)

Diabetes High Blood Pressure Heart Disease Pregnant/Nursing

Skin Type

Primary Skin Concerns (Check all that apply)

Acne/Breakouts Aging/Fine Lines Hyperpigmentation Dryness

Previous Spa Treatments

I understand that services at Divina Skin and Body Boutique are cosmetic and not a substitute for medical care.

I have provided accurate information about my health history and medications.

I consent to treatment and acknowledge the above statement. *

• 24-hour notice required for cancellations

• Late cancellations: 50% charge

• No-shows: 100% charge

I agree to the cancellation policy. *

Full Name (Signature) *

Date *