Date of birth *

MM

DD

YYYY

Cell Phone *

(###)

###

####

Alternative Phone

(###)

###

####

Please check all that apply:

Discoloration (Brown Spots or Melasma)

Fine Lines & Wrinkles

Dry, Flaky Skin

Rosacea

Dilated Capillaries Redness (Reactive Skin)

Combination

Enlarged Pores

Uneven Texture

Sun Damage

Acne/Breakouts Scarring

Oily Skin

Dark Under-Eye Circles

Loss of Facial Contours Lax or Sagging Skin

What type of skin do you think you have? *

Dry

Normal

Oily

If oily, are you oily throughout the cheek area?

Yes

No

Do you have a history of acne? *

Yes

No

If yes, are you using or have you ever used any medications for acne?

Yes

No

Do you sunbathe or participate in outdoor activities? *

Yes

No

Have you ever had a reaction to any skin care product or cosmetic? *

Yes

No

What skin care do you currently use? *

AM

PM

Please check if you are currently using or have used any of the following:

Retinol

Glycolic Acid

Lactic Acid

Salicylic Acid

Citric Acid

Resorcinol

Benzoyl Peroxide (BPO)

Hydroquinone

Tretinoin (Retin A) Renova®, Refisa®

Topical Antibiotics

Topical Steroids

Adapalene (Differin®)

Azelaic Acid (Azelex®, Finacea®)

Isotretinoin (Accutane®)

Extractions

Electrolysis

Laser Hair Removal

Waxing

Have you ever, or are you currently receiving skin treatments? Have you had any of the following?

Chemical Peels

Laser Resurfacing

Facial Cosmetic Surgery

Facial Injectibles

Permanent Cosmetics

Light Treatments

Microdermabrasion

Dermaplanning

Were there any complications?

Yes

No

Are you currently under the care of a physician? *

If yes, please discuss contraindications of any pre-existing medical conditions with your physician.

Yes

No

Are you currently taking any medications? *

Yes

No

Are you on hormone – replacement therapy?

Yes

No

Are you currently taking birth control pills?

Yes

No

Are you pregnant or breast feeding?

Yes

No

Please check the following conditions you have, or have had, in the treatment area:

Dermatitis

Eczema

Psoriasis

Cold Sores/Fever Blisters

Actinic Keratosis

Keloid Scarring

Open Sores or Lesions

Are you allergic to aspirin?

Yes

No