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PCA Chemical Peel and all skin treatments patient profile

(first page)

Dated: October 26, 2021

First Client's Name

First Name*

Last Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
First Client's Signature*
Second Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Third Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Fourth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Fifth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Sixth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Seventh Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Eighth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Ninth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
Tenth Client's Name

First Name*

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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
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.
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

Age *

Sex: *

About You:

What is your hereditary background? (check all that apply) *
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other - list below

Natural eye color: *

Natural hair color: *
Do you consider your skin (select the best option):*
Describe your skin (check all the apply):
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia
Broken surface capillaries

What are the changes you'd most like to see in your skin?

Lifestyle:

Are you pregnant or lactating? (Please consult with your obstetrician)*
No
Yes
Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.)*
No
Yes
Do you currently have a sunburned/windburned/red face?*
No
Yes

Why?
Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)*
No
Yes
Do you participate in vigorous aerobic activity or sports?*
No
Yes

What type?
Do you smoke or use tobacco?*
No
Yes

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Medical/Treatment History:

Do you currently use depilatories or wax?*
No
Yes

Discontinue use five days pre- and post-treatment or seven days when receiving MD Peel (CCl3.)

Have you had a chemical peel or any type of procedure with a medical device?*
No
Yes
Within the last 14 days?*
No
Yes

What type?
Do you have regular collagen, Botox®, or other dermal filler injections?*
No
Yes

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) 

Have you recently had laser resurfacing or facial surgery?*
No
Yes

Describe

When?
Are you currently taking any medications, topical or otherwise? (Tretinoin / Retin-A® / Renova® / Differin® / Tazorac® / Avage® / EpiDuo® / Ziana® )*
No
Yes

Which one(s)?

For how long?

What strength?

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment or seven days when receiving MD Peel (CCl3). Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*
No
Yes

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)
(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® , Sensi Peel® , Advanced Treatment Booster, Oxygenating Trio® , Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.

Do you develop cold sores/fever blisters?*
No
Yes

Last breakout?
Are you allergic/sensitive to (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone

If any other allergies, what?
Have you ever used any other products that caused a bad reaction?*
No
Yes

Describe
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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