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Date Signed: November 23, 2024

First Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

First Client's Signature*
Second Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Third Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Fourth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Fifth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Sixth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Seventh Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Eighth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Ninth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

Tenth Client's Name

First Name*

Middle Name

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

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*

Middle Name

Last Name*

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

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.


Best Contact Number
Is it ok to text this number?*
No
Yes

FACTORS THAT EFFECT SKIN HEALTH 

1. Are you a smoker?*
No
Yes
2. Are you pregnant?*
No
Yes
3. Are you currently under the care of a physician?*
No
Yes

If yes, for what condition(s)?

Allergies
Have you been diagnosed or treated for the following within the last 24 months? (check all that apply)
Eczema
High blood pressure
Cancer
Psoriasis
Blood clots
Acne
Hormone therapy
Cold Sores
Diabetes
Other

If Other

What medications and supplements are you currently taking?
Your daily stress level is:*

Occupation

How many ounces of water do you drink per day?

How often do you exercise?
Do you have any metal implants in your body?*
No
Yes

If yes, where?

YOUR SKIN


What is the primary reason for your visit today?

What is the most important improvement you would like to see in your skin?

Please list any cosmetic procedures you have had in the last 12 months

What skincare line are using?

Describe your daily skin care routine
How often do you wear sunscreen?*
Have you received any of the following procedures within the last 6 months?
Microdermabrasion
Facial Injections (Botox, Fillers)
Derma-plane
Waxing
Micro-needling (CIT, PRP)
Laser Procedures
Other

Other

I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.

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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