Date of Birth
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City, State, Zip:
Do you work outside?
Emergency Contact Phone:
What would you like to achieve from your treatment today?
Do you currently have or have ever had any of the following?
Herpes or Cold Sores
Prone to Cold Sores
High Blood Pressure
Are you pregnant, possibly pregnant or breast feeding?
List current medications:
List all allergies (food, environmental, medication, etc):
Are you using or have you used any of the following?
Retinoids (Retin-A, Renova, etc)
Hydroquinone (Lustra, Tri-Luma, etc)
Alpha or Beta Hydroxy Acids
Topical acne or skin medications
Have you ever reacted to any skincare products?
If so, what kind of product and what was the reaction?
Have you seen a dermatologist in the past year?
Have you ever had a facial treatment before?
If so, when?
How is your skin during the day?
Oily all over
Shiny in T-Zone
Tight, Dry or Flaky
Red or Irritated
Normal, no issues
When you sunbathe or get accidental sun, how does your skin respond?
Always burns, never tans
Burns easily, tans poorly
Burns moderately, tans gradually
Occasionally burns, tans easily
Rarely burns, tans very easily
Never burns, always tans darkly
Have you ever had any of the following?
Botox, Fillers, Injectables
LED Light Therapy
What areas of concern do you have? (Check all that apply):
Uneven skin tone
What skin care products are you currently using? (List brand where known)
Have you recently used any self-tanning products or received spray tan treatments?
If so, what kind and when?
Have you used any of the following hair removal methods in the past 6 weeks?
Have you had face or body waxing in the past week?
What SPF do you use on your face?
What SPF do you use on your body?
Have you used a tanning bed or been sun tanning in the past 2 weeks?
Should be Empty: