4T Medical Cosmetic Set Form

Name *

First

Last

Date of birth: *

Phone number *

Email *

Order number *

1. What skincare products do you use in the morning? (Please list the products and brands, if possible.)

2. What skincare products do you use in the evening? (Please list the products and brands, if possible.)

you specific tone,

3. Are you currently taking any medications? (If yes, please list them.)

4. Do you have any known allergies? (If yes, please specify.)

5. What are your main skin concerns? (e.g., acne, dryness, sensitivity, hyperpigmentation, etc.)

Other (please specify):

7. Are there any specific skin issues you are struggling with? (Please describe.)

8. What would you like to achieve with your beauty treatments? (e.g., clearer skin, reduced signs of aging, even skin tone, etc.)

9. Do you have any specific goals or outcomes in mind? (Please elaborate.)

10. Is there anything else you would like us to know before your treatment? (e.g., previous treatments, lifestyle habits, etc.)

Consent and Agreement: I understand that the information provided above is accurate to the best of my knowledge. I consent to the use of this information to tailor my beauty treatment.

Data Consent: By filling out this form, I give my consent to Harmony Aesthetic to store my personal data and to contact me regarding my beauty treatments.