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Dated: September 21, 2019

Please select who will be participating...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Work Phone

Cell Phone

Ethnicity

Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):

Antibiotics*
No
Yes

When / How Long
Accutane*
No
Yes

When / How Long
Benzoyl Peroxide*
No
Yes

When / How Long
Clindamycin Topical*
No
Yes

When / How Long
Adapalene*
No
Yes

When / How Long
Retin A Cream or Ge*
No
Yes

When / How Long
Tazorac*
No
Yes

When / How Long
Differin*
No
Yes

When / How Long
Azelex*
No
Yes

When / How Long
Sulfur*
No
Yes

When / How Long
Clindamycin Oral*
No
Yes

When / How Long
Androstendione*
No
Yes

When / How Long
Cortisone*
No
Yes

When / How Long
Minocycline*
No
Yes

When / How Long
Copaxone*
No
Yes

When / How Long
Testosterone*
No
Yes

When / How Long
Progesterone*
No
Yes

When / How Long
Disufuram*
No
Yes

When / How Long
Cyclosporin*
No
Yes

When / How Long
Dilantin*
No
Yes

When / How Long
Lithium*
No
Yes

When / How Long
Thyroid Medication*
No
Yes

When / How Long
Quinine*
No
Yes

When / How Long
Isoniazid*
No
Yes

When / How Long
Immuran*
No
Yes

When / How Long
Danzol*
No
Yes

When / How Long
Gonadotrophin*
No
Yes

When / How Long
Steroids*
No
Yes

When / How Long
Recreational Drugs*
No
Yes

When / How Long
Antidepressants*
No
Yes

When / How Long

Products now using - please write product name


Cleanser

Toner

Serums

Moisturizers

SPF

Mask

Foundation

Blush

Exfoliant (ex. Glycolic)

Acne Medications
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?*
No
Yes

If yes, what product:

Describe:
Check if you are allergic to:
sulfur
aspirin
latex
Do you smoke?*
No
Yes

Lifestyle Considerations


At what age did your acne start?
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you pick at your skin?*
No
Yes
Do you work around chemicals, tars, oils or inks?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
Do you regularly eat or ingest:
kelp
seaweed
sushi
salt
fast foods
milk/cheese

Women only: Are you on birth control pills? If yes, name of pill
Are you taking Depo Provera shots?*
No
Yes
Are you pregnant or nursing?*
No
Yes
What are your skin care concerns:
Blackheads
Whiteheads
Pimples/Pustules
Cysts
Oily Skin
Dehdyrated Skin
Dark Spots
Age Spots
Broken Capillaries
Fine Lines/Wrinkles
Dry,Flaky Skin
Sensitive Skin
Razor Bumps
Shaving Irritation
Acne Rosacea
Describe your skin:*

What else have you done for your skin:

Glycolic Acid Peels*
No
Yes

When
Microdermabrasion*
No
Yes

When
Chemical Peels*
No
Yes

When
Skin Cancer Removal*
No
Yes

When
Plastic Surgery*
No
Yes

When
Laser Hair Removal*
No
Yes

When
Facial Waxing*
No
Yes

When
Electrolysis*
No
Yes

When

Anything else?
Medical History: check any condition you may have had in the past two years
Diabetes
Thyroid Problems
Eczema
Psoriasis
Pregnancy
Nursing
Cancer
Hepatitis
HIV + or AIDS
Staph Infection or MRSA
Hormone Problems
Herpes Simplex/Cold Sores
High Blood Pressure
Anemia
Hemophilia
Thrombosis/Blood Clot/Stroke
Metal pins or brackets in body
Pacemaker
Hysterectomy/ovaries removed
PCOS
Lupus
Are you under a Dermatologist's Care?*
No
Yes

If so, name of Dr.

What kind of work do you do?

How did you hear about us?

What results would you like to obtain with your skin?
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Work Phone

Cell Phone

Ethnicity

Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):

Antibiotics*
No
Yes

When / How Long
Accutane*
No
Yes

When / How Long
Benzoyl Peroxide*
No
Yes

When / How Long
Clindamycin Topical*
No
Yes

When / How Long
Adapalene*
No
Yes

When / How Long
Retin A Cream or Ge*
No
Yes

When / How Long
Tazorac*
No
Yes

When / How Long
Differin*
No
Yes

When / How Long
Azelex*
No
Yes

When / How Long
Sulfur*
No
Yes

When / How Long
Clindamycin Oral*
No
Yes

When / How Long
Androstendione*
No
Yes

When / How Long
Cortisone*
No
Yes

When / How Long
Minocycline*
No
Yes

When / How Long
Copaxone*
No
Yes

When / How Long
Testosterone*
No
Yes

When / How Long
Progesterone*
No
Yes

When / How Long
Disufuram*
No
Yes

When / How Long
Cyclosporin*
No
Yes

When / How Long
Dilantin*
No
Yes

When / How Long
Lithium*
No
Yes

When / How Long
Thyroid Medication*
No
Yes

When / How Long
Quinine*
No
Yes

When / How Long
Isoniazid*
No
Yes

When / How Long
Immuran*
No
Yes

When / How Long
Danzol*
No
Yes

When / How Long
Gonadotrophin*
No
Yes

When / How Long
Steroids*
No
Yes

When / How Long
Recreational Drugs*
No
Yes

When / How Long
Antidepressants*
No
Yes

When / How Long

Products now using - please write product name


Cleanser

Toner

Serums

Moisturizers

SPF

Mask

Foundation

Blush

Exfoliant (ex. Glycolic)

Acne Medications
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?*
No
Yes

If yes, what product:

Describe:
Check if you are allergic to:
sulfur
aspirin
latex
Do you smoke?*
No
Yes

Lifestyle Considerations


At what age did your acne start?
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you pick at your skin?*
No
Yes
Do you work around chemicals, tars, oils or inks?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
Do you regularly eat or ingest:
kelp
seaweed
sushi
salt
fast foods
milk/cheese

Women only: Are you on birth control pills? If yes, name of pill
Are you taking Depo Provera shots?*
No
Yes
Are you pregnant or nursing?*
No
Yes
What are your skin care concerns:
Blackheads
Whiteheads
Pimples/Pustules
Cysts
Oily Skin
Dehdyrated Skin
Dark Spots
Age Spots
Broken Capillaries
Fine Lines/Wrinkles
Dry,Flaky Skin
Sensitive Skin
Razor Bumps
Shaving Irritation
Acne Rosacea
Describe your skin:*

What else have you done for your skin:

Glycolic Acid Peels*
No
Yes

When
Microdermabrasion*
No
Yes

When
Chemical Peels*
No
Yes

When
Skin Cancer Removal*
No
Yes

When
Plastic Surgery*
No
Yes

When
Laser Hair Removal*
No
Yes

When
Facial Waxing*
No
Yes

When
Electrolysis*
No
Yes

When

Anything else?
Medical History: check any condition you may have had in the past two years
Diabetes
Thyroid Problems
Eczema
Psoriasis
Pregnancy
Nursing
Cancer
Hepatitis
HIV + or AIDS
Staph Infection or MRSA
Hormone Problems
Herpes Simplex/Cold Sores
High Blood Pressure
Anemia
Hemophilia
Thrombosis/Blood Clot/Stroke
Metal pins or brackets in body
Pacemaker
Hysterectomy/ovaries removed
PCOS
Lupus
Are you under a Dermatologist's Care?*
No
Yes

If so, name of Dr.

What kind of work do you do?

How did you hear about us?

What results would you like to obtain with your skin?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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