KISSED CLINIC INTAKE
Start Your Healing Journey
the Right Way

KISSED CLINIC INTAKE FORM

SECTION 1: BASIC INFORMATION

First Name

Last Name

Phone

How would you like to receive services?

SECTION 2: PRIMARY CONCERN

What is your primary concern?

How long have you been experiencing this concern?

SECTION 3: MEDICAL + HISTORY

Have you seen a doctor, dermatologist, or specialist for this issue? If yes, please explain.

Are you currently taking any medications or supplements? Please list.

Have you experienced any of the following recently: stress, trauma, surgery, illness, pregnancy, or hormonal changes? Please explain.

SECTION 4: COMMITMENT + INTENT

If recommended, are you open to investing in a 12-week healing protocol?

Yes, I am ready

I need more information

Not sure yet

What results are you hoping to achieve?

SECTION 5: CONSENT (IMPORTANT)

Agreement / Consent:

I understand that this intake form is required before booking services and does not guarantee results. I agree to provide accurate information.

**After submitting this form, you will be directed to book your clinic service so we can review your results and begin your personalized plan.

Before booking your appointment, we need to understand your hair, scalp, and wellness concerns so we can guide you properly.

This form takes 2-3 minutes to complete.