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Skin Care Form

PLEASE INITIAL:

I agree that the nature and purpose of the treatment will be explained to me my appointment time, and any questions I have regarding the treatment will be discussed. 

I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.

I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.

I do not have active cold sores.

I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.

I understand that it is recommended prior to having a facial infusion to not have used Retin A for 72 hours, Accutane in 6 months or have waxed 24 hours prior to receiving treatment.

Today's date: September 28, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
Participant'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.
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
May we leave a message if we do not reach you personally?*
No
Yes

WHAT ARE YOUR TOP 3 SKINCARE CONCERNS:

MEDICAL HISTORY:

Pregnant?*
No
Yes
Breastfeeding?*
No
Yes
Do you smoke?*
No
Yes

Health Conditions:

Past Surgeries:
Have you ever been diagnosed with Cancer?*
No
Yes

If yes, last treatment date:

Current Medications:

Prescription Topicals:

Allergies (include aspirin & iodine):

PREVIOUS TREATMENTS:

Facials:*
No
Yes

If yes, last treatment:

Any Complications?
Microdermabrasion:*
No
Yes

If yes, last treatment:

Any complications?
Chemical Peels:*
No
Yes

If yes, last treatment:

Any complications?
Waxing:*
No
Yes

If yes, last treatment:

Any complications?
Tanning:*
No
Yes

If yes, last treatment:

Any complications?
Laser Therapy:*
No
Yes

If yes, last treatment:

Any complications?
Massage:*
No
Yes

If yes, last treatment:

Any complications?
SKIN CONDITIONS: (please check all the items below that pertain to you)
Skin Infection
Herpes (cold sores)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Bruising
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
SKINCARE: What type of skin do you feel you have?
Dry
Oily
Normal
Combination

What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
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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