Name (Last, First) *

Date of Birth *

Email *

Phone *

Address, City, State, Zip Code *

Occupation

Have you had a facial treatment before?

Do you have any skin problems or concerns pertaining to your face & body?

Which of the following best describes your skin type?(Please check one)

Have you ever had chemical peels, laser treatments, or microdermabrasion? If yes, When was your last treatment?

Do you use any topical or internal products like Accutane, Retin A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products

If yes, please specify these products:

Are you or have you used any topical creams, lotions or oral antibiotics for acne, cancer, anti-aging or hyperpigmentation?

If your answer is yes, please specify:

Do you take any medications that cause a light sensitivity?

If so, please include more info:

Have you had any of the following injectables or cosmetic surgeries/procedures?

Have you used any hair removal methods in the past six weeks?

Do you experience irritation from shaving?

Do you experience ingrown hairs as a result of hair removal?

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or get marks after physical trauma?

If yes, please describe in more detail:

Do you form thick or raised scars from cuts or burns?

What areas of concern do you have regarding your skin? (Check all that apply)

What areas of concern do you have regarding your eyes?

What areas of concern do you have regarding your lips?

Have you ever had an allergic reaction to any of the following?

Have you recently been in a tanning bed, had sun exposure, or used a self-tanning lotion, cream or any product that would alter the color of your skin?

Are you taking any oral contraceptives?

If yes, please specify:

Have you experienced any recent changes to or from your contraceptives?

If yes, please specify

Are you pregnant, breast feeding or trying to get pregnant?

Are you experiencing any menopause symptoms?

Are you currently undergoing any hormone therapy treatments?

Do you have a history of or have any of the following?

Do you have a history of skin cancer?

How many glasses of water do you drink daily?

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume daily?

How many alcoholic beverages do you consume per week?

How many hours of sleep do you get per night?

Which foods do you consume on a regular basis?

How often do you travel on a plane?

How many hours daily do you spend in front of a screen or digital device?

Do you exercise on a regular basis?

Do you smoke cigarettes, vape or consume tobacco related products?

Do you swim in a chlorinated pool for exercise or soak in a jacuzzi?

What are your stress levels on a scale from 1-5?

What skincare products are you currently using?

Which skin care products are you interested in adding to your regimen?

Is there anything else you would like me to know?

Have you had a fever in the last 24 hours of 100°F or above? *

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, shortness of breath, diarrhea? *

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

I understand that because the practice of esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner. *

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skincare professional from liability and assume full responsibility thereof. *