Ethan Look –

Full Name: Ethan Look
Date of Birth: 1996-02-05
Email Address:
Emergency Contact: Dara Potts, 6507143338
Medical History : Other, – n/a
Additional Details : n/a
Have you been under the care of a dermatologist within the past year? Yes, – general skin health
Are you taking any medications or dietary supplements? No, –
Have you had any surgery in the last 12 months? No, –
Have you received Botox, Restylane, Collagen or any other injections in the last 6 months? No, –
Do you wear contact lenses? Yes, – acuve daily
Is there anything that may be important for us to know? no
For ladies: Are you pregnant, planning a pregnancy, breastfeeding, using birth control or menstruating? Array
For ladies: Are you taking birth control pills? No,
Body Concerns:Muscular Tension, –
What is your current facial care routine? cleanser, moisturizer, spf

Facial concerns: Other (please specify), – n/a
What is your current body care routine? n/a

Name : Ethan Look
Signature :

Enter Date : 2022-05-12

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