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FACIAL CONSULTATION

Today's Date: December 2, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
First Participant's Signature*
Second Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Third Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Fourth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Fifth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Sixth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Seventh Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Eighth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Ninth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Tenth Participant's Name

First Name*

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

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, please describe?
5. Have you used any of these products in the last 3 months?*
No
Yes

If YES, please describe?
6. Have you used an acne mediciation?*
No
Yes

If YES, when?

If YES, please describe?

7. What skin care products are you currently using, please list brand when known?
8. Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

If YES, please describe?
9. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
10. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
11. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
OTHER

If YES, please describe?

12. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACNE
BLACKHEADS/WHITEHEADS
EXCESSIVE OIL/SHINE ROSACEA
BROKEN CAPILLARIES
REDNESS/RUDDINESS
SUN SPOT/LIVER SPOT/BROWN SPOT
UNEVEN SKIN TONE
SUN DAMAGE
WRINKLES/FINE LINES
DULL/DRY SKIN
FLAKY SKIN
DEHYDRATED
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER

Please advise below of any other medical conditions we should be aware of
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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