client consultationYour health and wellness is our priority. Prior to your appointment, please submit the form below: Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Your Health Within the last year, have you been under a physician's care? * Yes No Please specify any health problems you have had in the past or present. * Do you have a metal implant, pacemaker, or body piercings? * Yes No Do you have a heart murmur, seizures, or epilepsy? * Yes No Your Skin Do you have skin problems pertaining to your face or body? If yes, please specify: Have you ever had a facial before? * If so, when? Exfoliation History Are you currently using products that contain the following ingredients? glycolic acid lactic acid any exfoliating scrubs any hydroxy acid product vitamin a derivatives such as retinol retina-A acutane Have you ever had chemical peels, microdermabrasion, or resurfacing treatments? * Yes No If yes to the above, in the last month? Female Clients Only Are you pregnant or planning to become pregnant? * Yes No I certify that the information I have provided on this consultation card is accurate, to the best of my knowledge, and that I have not withheld any information that will be relevant to my treatment. * Provide a digital signature and date below: This consultation card is to correctly evaluate your special skincare needs. This information is confidential and may be disclosed to only staff members, risk management, or quality improvement personnel to assess the quality of care and will not be passed to a third party. What are your skincare goals? Do you spend time in the sun? * Do you or have you used a tanning bed? * Do you use sunscreens? * Do you remove your makeup at night? * What type of skincare products are you currently using? Do you or have you had any allergic reactions to any skincare products that you are aware of? * Do you know how to use basic skincare products? How do you feel about facial massages? * Text Have you ever had any of the following conditions from: Cold sores or fever blisters, Eczema, Dermatitis, Psoriasis, Keloid Scarring, Open Sores or Lesions Yes No Acne History Have you ever had a history of acne and are you currently taking medication or have you ever taken any acne medications? Yes No Do you sunbathe or participate in outdoor activities? Yes No Have you ever had any of the following? Chemical Peels Laser Resurfacing Facial Cosmetic Surgery Facial Injectables Permanent Cosmetics Light Treatments Microderm Abrasion Dermaplanning Extractions Electrolysis Laser Hair Removal Waxing Please check off any medications you are currently using or have used Retinol Glycolic Acid Citric Acid Resorcinol Benzoyl Peroxide Hydroquinone Tretinoin Topical Antibiotics Topical Steroids Isotretinoin (Accutane) Adapalene (Differin) Thank you!
