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Skin Care Consutlation Form

Please read and initial that you understand the following policies:

LATE ARRIVALS: We regret that late arrival for your appointment may deprive you of valuable treatment time.

CANCELLATION POLICY: If it is necessary to change your appointment, we request you do so a mininum of 3 hours in advance for an individual appointment or 48 hours in advance for a spa party of 2 people or more. This time is especially reserved just for you and if the appointment is not cancelled, we are not able to offer the time to another guest. Regretfully, if we do not receive the adequate notice of cancellation, $25 cancellation or a no show fee will be charged to the card on file for each service scheduled. If there is no card on file, the full amount of the missed service will be collected before another appointment can be scheduled.

MEDICAL: For your protection, please inform us of any medical conditions or other special needs that may require our attention to make your visit a pleasant one. This includes skin care products that may interfere with facial and waxing services. In the event your health history changes, please notify us and complete a new Skin Care Consultation Form.

I understand that any sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

I hereby acknowledge that I have been provided this notice that the skin care service to be received will be provided by Estheticians who are independent contractors. I acknowledge that such independent contractors are not employees of Essentials Massage & Facial Spa of Pasadena. Therefore, liability, if any, that may arise from the skin care service is limited as provided by law. I hereby certify that I am the individual receiving the skin care service or a person who is authorized to give consent for the skin care service recipient.

Today's Date: March 21, 2019

First Client's Name

First Name*

Last Name*

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

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

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

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

Personal Information

What is your current stress level?
Low
Moderate
High
When exposed to the sun do you:
Always burn (Type 1)
Usually burn (Type 2)
Sometimes burn (Type 3)
Rarely burn (Type 4)
Never burn (Type 5 & 6)
What is your skin type?
Normal
Dry/Dehydrated
Combination
Oily
Sensitive/Redness
What are your skin concerns?
Firm skin: Anti-aging
Smooth skin:Texture
Bright skin: Hyperpigmentation
Clear skin: Acne & breakouts
Calm skin: Sensitivity
Other: please describe below

What are your skin care goals?

What skin care products are you currently using at home?
Have you ever experienced any of the following?
Rosacea
Broken capillaries
Dermatitis
Keloid scarring
Hypopigmentation
Hyperpigmentation
Skin cancer
Eczema
Psoriasis
Please check any of the following that are applicable:
Anemia
Asthma
Autoimmune
Braces/dental fillings
Cancer
Claustrophobia
Cold sores/Herpes Simplex
Contact lenses
Diabetes
Epilepsy/seizures
Heart attack
Hepatitis
High cholesterol
High/low blood pressure
Hormonal imbalance
Irregular heartbeat
Lupus
Metal implants/pacemaker
Piercing(s)
Recent dental x-rays
Stroke
Thyroid disorder
Tobacco user/smoker
Varicose veins
Other
Are you currently using any of the following prescription products?
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
Adepalene (Differin®)
Azelaic Acid (Azelex®, Finaea™)
Tazarotene (Tazorac®)
Isotretinoin (Accutane)
Triluma™
Metrogel™
Hydrocortisone
Other (please list below)

Please list "other"

Please list all supplements and/or vitamins you take on a regular basis:
Are you currently under a treatment plan? If yes, please explain below.*
No
Yes

List Medications:

Treating Physician:
In the last 14 days have you had any of the following:
Botox
Dermal fillers
Laser Resurfacing
Cosmetic Resurfacing
Chemical Peels or Microdermabrasion

Please list all known allergies:

Do you have any allergic reaction to the sun, chemical peels or any skin care products?
Are you pregnant or nursing?*
No
Yes
Are you on hormone therapy?*
No
Yes

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). 

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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