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Studio Rejuvé Nation Client Intake



Treatment Consent

Please read carefully. By signing this form, you acknowledge that you understand and agree to the following

Virtual skin consultations and coaching are cosmetic in nature and do not replace medical advice or treatment. No medical diagnoses or guarantees of results are made.

I understand that achieving the best results may require multiple sessions and consistent follow-through with recommended home-care routines. I acknowledge that some sessions may involve guidance or recommendations for clinical-strength products, acids, enzymes, or tools like LED therapy or high-frequency treatments, depending on my skin’s needs.

I understand that while these treatments and recommendations are designed to improve skin health and appearance, there are potential risks, including temporary discomfort like tingling, tightening, or mild irritation. Results cannot be guaranteed because everyone’s skin, age, and lifestyle factors are different. Additional sessions or products may be recommended, which may incur additional costs.

I agree to follow all guidance provided, including post-consultation and home-care instructions, and to contact my provider if I have any questions or concerns. I commit to avoiding tanning or excessive sun exposure during and for at least 14 days after any recommended treatments, and I understand that regular sun protection is essential.

I confirm that all information I provide about my medical history, allergies, medications, or products I currently use is accurate to the best of my knowledge. I will disclose any conditions that might affect the recommendations, including pregnancy, history of cold sores, allergies, recent facial procedures, laser treatments, or medications such as Accutane.

I understand that Studio Rejuvé Nation, including Lis Anne Humphrey, is not responsible for any complications that arise from undisclosed or incomplete information. I release Studio Rejuvé Nation from liability related to any pre-existing or undisclosed conditions.

I understand that my personal information will remain confidential and will not be sold or shared. I attest that the information I provide is true and complete.

I acknowledge that Studio Rejuvé Nation does not provide medical diagnoses and that it is my responsibility to consult a licensed physician for medical concerns. I also understand that incomplete or inaccurate information could result in irritation or other complications, and I will notify my provider of any changes between sessions.

By signing this form, I confirm that I have read and understood this agreement, had the opportunity to ask questions, and consent to receive virtual skin consultations and coaching from Studio Rejuvé Nation.

Acknowledge *

I understand and agree to everything stated above. I consent to the use of electronic documents and signatures.

I Agree

Client/Parent/Guardian Signature:

I acknowledge my understanding of and commitment to adhere to all the policies of Studio Rejuvé Nation:


1. Studio Rejuvé Nation reserves the right to decline services for clients with uncertain or active medical conditions, including but not limited to Herpes Simplex (fever blisters or active cold sores), open wounds or sores, healing incisions, or infectious diseases.

2. All virtual services and packages at Studio Rejuvé Nation are final sale and paid in full at the time of booking. We understand that unforeseen circumstances may arise, and clients are allowed one courtesy reschedule when requested at least 24 hours prior to the scheduled appointment. Cancellations or reschedule requests made within 24 hours of the appointment will result in the forfeiture of the scheduled session. In the event of a no call, no show, the session will be marked as used and forfeited. All virtual packages are non-refundable and non-transferable, and missed sessions cannot be credited or rebooked.

3. I understand that the services provided are not a substitute for medical care. Any information shared during sessions is intended for educational purposes only.

4. All information provided by the client is completely private and will be kept strictly confidential.

I acknowledge that all payments and purchases are final.

Acknowledge *

I understand and agree to everything stated above. I consent to the use of electronic documents and signatures.

I Agree

Client/Parent/Guardian Signature:

January 24, 2026

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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(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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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*
Date of Birth
Information
How did you hear about Studio Rejuvé Nation?
I would like:
Help with addressing my skin concerns
Help with my home care regimen
A purposeful, results-driven experience
Is this your first virtual skin consult?*
No
Yes

If no, please specify the last consult you've had in the past:

Skin Concerns

What are your primary skin concerns? (PLEASE SELECT ALL THAT APPLY) *
Acne / Blemishes
Acne Scars
Age Spots
Dehydration
Dull Skin
Enlarged Pores
Fine Lines
Hyperpigmentation
Loss of Elasticity / Firmness
Rosacea / Redness
Sun Damage
Uneven Skin Texture
Sensitivity
Other
If "other" please specify:
How would you describe your skin type?*
Do you or have you ever had an allergic reaction or sensitivity to any of the following? *
Alpha Hydroxy Acids
Aspirin
Pollen
Latex
Cosmetics
Fish / Marine / Iodine
Food / Nut
Sunscreen
Other
None
Please specify: (OPTIONAL)

PLEASE READ CAREFULLY

STUDIO REJUVÉ NATION WILL NOT BE RESPONSIBLE FOR ANY ALLERGIC REACTIONS IN RELATION TO UNDISCLOSED MATTER. 

How would you describe your skin's response to sun exposure? *

Regimen 

Do you currently have a skin care regimen?*
No
Yes
What products do you currently use? (PLEASE SELECT ALL THAT APPLY) *
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Eye Care
Lip Care
None

Please specify:


Product, Brand, Frequency
Do you currently or have you ever used Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin? *
No
Yes, currently
Yes, but not in the last 14 days
Yes, but not in the last 30 days
If yes, please specify: (Retinol, Retin-A / Tretinoin, Adapalene, Accutane or Differin)

PLEASE READ CAREFULLY

PLEASE AVOID USING RETINOL, RETIN-A, TRETINOIN, ADAPALENE, ACCUTANE OR DIFFERIN 14 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

PLEASE AVOID USING EXFOLIANTS / SCRUBS 7 DAYS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU ARE CURRENTLY OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE SCHEDULING YOUR APPOINTMENT. 

Have you recently received a chemical peel, microneedling, or cosmetic laser treatment? *
No
Yes, within the last 30 days
Yes, within the last 2+ Months
Yes, within the last 6+ Months
Have you received Botox or filler in the last 14 days?*
No
Yes

Medical History 

Medical History (PLEASE SELECT ALL THAT APPLY) * *
Cancer / Radiation
Depression / Anxiety
Eczema
Hemophilia
Hepatitis A, B or C
Hormone Problems
Fever Blisters / Cold Sores
Staph Infection / MRSA
HIV/AIDS
Thyroid Problems
Hysterectomy
Ovary(ies) Removed
Migraines / Headaches
Lupus
High Blood Pressure
Diabetes
Metal Pins in Body
Hypotension
Epilepsy / Seizures
Digestive Imbalance
Skin Disease
Cardiac Problems
Sinus Problems
Immune Disorders
Keloid Scarring
Blood Clot Disorder
Asthma
Arthritis
Autoimmune Disease
Rosacea
Menopause
Claustrophobia
Hormonal Imbalance
Stroke
Bruise Easily
Varicose Veins
Other
None
If selected "other", please specify:
Are you currently on any blood thinners? *
No
Yes

Your Primary Care Physician

Are you currently under a dermatologist's or physician's care for any current skin condition?*
No
Yes
If yes, please specify dermatologist's or physician's name
Facility Name

Lifestyle

What 2-3 concerns are you sometimes affected by?
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Stress
Worry / Overthinking
Anxiety
Hard Time Breathing
Lack of Patience
Poor Circulation
Hyperactivity
Other
If selected "other", please specify:
Do you wear contact lenses?*
No
Yes
Do you smoke / Vape? *
No
Yes
If yes, what do you smoke?
Frequency
Do you consume alcohol?*
No
Yes
Frequency
Do you use fabric softener or fabric softener sheets in the dryer?*
No
Yes
Do you swim in a chlorinated pool?*
No
Yes
Occupation
Do you work around chemicals, tars, oils, grease or inks?*
No
Yes
Do you work nights?*
No
Yes
Are you currently under a lot of stress?*
No
Yes
How would you describe your stress level on a scale of 1 - 5? (1 = Very Low / 5 = Very High) *
Are you on birth control? (pills, shots or use an IUD) *
Yes
No
N/A
If yes, which do you use?
Are you pregnant or nursing?*
Yes
No
N/A
Do you have irritation on your face after shaving?*
Yes
No
N/A
What type of razor do you use for shaving? (double blade, triple blade, rotary) You may skip if it does not apply.
Are you sensitive to fragrances?*
No
Yes
If yes, please specify:

Diet

Are you currently on a special diet? (i.e Keto, Vegan, Vegetarian, Gluten- free etc.)*
No
Yes
If yes, please specify:

How often do you consume the following foods? 

Fast Food*
Processed Food*
Salty Snacks*
Milk / Yogurt*
Cheese*
Whey or Soy Protein*
Peanut Butter*
Peanuts*
Sushi*
Kelp and Seaweed*
Miso Soup*
Soy*
Vitamins / Supplements*
Seafood*

Photo Release Consent 

Do you consent to your photos being used on social media for marketing purposes?*
No
Yes
Do you consent to your photos being taken to monitor your treatment progress?*
No
Yes

If yes, please sign below.

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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