Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Describe your skin

Check all that apply.

Normal

Oily

Dry

Combination

Sensitive

Resilient

Thin

Thick

Saggy

Firm

Mature

Wrinkes

Sun Damage

Melasma

Uneven Skin tone

Hyperpigmentation

Acne

Acne Scars

Blackheads

Large Pores

Redness

Broken Surface Capillaries

Milia

Other

Check if you ever had allergies to:

Check all that apply.

Medicines

Soaps

Cosmetics

Sun

Food

Plants

Other

Check if you have any of the following conditions.

Check all that apply.

Bleeding Problems

Diabetes

High Blood Pressure

Current Cancer

Recent Chemotherapy or Radiation Therapy

Immunocompromised (AIDS/HIV/immunosuppressive meds)

Herpes/Cold Sores

Are you using any of these medications?

Check all that apply.

Tretinoin

Retin A

Renova

Differin

Tazorac

Avage

Epiduo

Ziana

AHAs

Retinol / Vitamin A Products

Have you had Accutane within the last 12 months? *

Yes

No

Are you currently pregnant or nursing *

Yes

No

Office Policies *

Payment is due in full via cash, debit/credit card, or Venmo at the end of each appointment. We request a minimum of 24 hours notice to cancel or change your appointments. Failing to give us 24 hours notice will result in a charge of $20 or 50% of the scheduled service, whichever is greater. No-shows will be charged 100% of the service price. Any outstanding balance must be paid before you can book another appointment. A parent must accompany clients under 18 during the consultation. Clients under 16 must have a parent present during all treatment sessions. Do you agree to these terms?

Yes

No

Today's Date *

MM

DD

YYYY