Facial Intake

1. Facial Intake *
2. Does your job require you to work outside? *
3. What would you like to achieve from your treatment today? *
4. Have you ever had a facial treatment before? *
5. If Yes, when was your last facial?
6. Have you ever had a chemical peel, laser treatment, or microdermabrasion? *
7. If Yes, in the last 30 Days?
8. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products, Deferin, Glycolic Acid, AHA, Salicylic Acid? *
9. If Yes, have you used these products in the last 3 months?
10. Have you used any acne medication? If Yes please list when and which drug you used?
11. Rate your daily skin care routine: *
12. Please check skin care products you are currently using
13. What skin care brands have you used? Anything else we should know?
14. What areas of concern do you have regarding your skin: Check all that apply *
15. Are you in good health *
16. Do you have any allergies to foods or medications *
17. If yes, please list:
18. List any topical medictaions
19. For the purpose of chemical peels and skin tone please list your ethnic background *
20. How do you heal after a breakout, cut or scratch? *
21. Are you prone to cold sores? *
22. Do you smoke *
23. Have you experienced Botox, Restylane, or Collagen Injections? Please list last treatment and specify?
24. Do you wear contacts? *
25. Do you have metal implants or wear a pacemaker? *
26. Have you been exposed to the sun or tanning bed in the last 48 hours? *
27. Are you interested in Chemical Peels? *
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 disclosures. I understand that it is my responsibility to inform the esthetician/skin care therapist of my current medical and/or health medical conditions and do not hold my service provider liable for information that has not been disclosed.I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.I have been informed of possible benefits, risks, and complications. I understand that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at and additional cost. I have read and understand the post-treatment care instructions. I understand how important it is to follow all instructions given to me for post treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.I do not hold the esthetician responsible for any of my condition that were present,but not disclosed at the time of this skin care procedure, which may be affected by treatment performed today
Please sign below if you agree with the above statements.