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THE SCARED MOTHER RITUAL FACIAL
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Sacred Mother Ritual Intake Form
First name
Last name
Birthday
Month
Day
Year
Email
*
Phone
*
Emergency Contact Name & Number
*
Relationship
*
How many weeks pregnant are you?
Is this your first pregnancy?
Single choice
Yes
No
Is there anything about your pregnancy or health you would like to share or anything I should be aware of?
What are your goals or intentions for this Sacred Mother Ritual?
Please share any medical information, conditions, medications, supplements, restrictions, or sensitivities that may be relevant to your care or that I should be aware of:
Do you have any areas of discomfort, swelling, or sensitivity that need to be avoided?
How would you describe your skin? (Dry, Oily, Combination, Changes Seasonally):
Current skincare routine / products used:
Any harsh treatments in the last 30 days (chemical peel, laser, etc.)?
Sensitivities to light, touch, sound, or smell? Please explain:
Allergies
Contact lenses?
Hair extensions?
Photo & Media Consent
Multi choice
Yes, may be used publicly on website, social media, or marketing material.
Yes, for educational purposes only (not publicly posted.
No, I do not consent to photos or videos being taken or used.
Signature
*
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Date:
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