Today's Date:

Name:
Date Of Birth:
Telephone:
Cell Phone:
Email:
Occupation:
Male Female

By answering the following questions, the therapist will be better able to recommend products that are appropriate for your skin needs and bring the results you desire.  Please be assured that any information you submit will remain confidential and we will never give your personal information to any other business or persons.

Are you now using (or used in the past):

      Azelex     Differin     Renova     Retin-A   Tazarac     

     Glycolic or alphahydroxy acids             

If so, when and for how long?
 

Are you now using or have you ever used Accutane?     Yes     No

If so when and for how long?

Do you have acne?    Yes     No

Experience frequent blemishes?          Yes     No

If so how frequently?

Do you have ANY allergies to cosmetics, foods, or drugs?         
Yes     No

       If so, please list:

Are you currently taking medications - oral or topical? 
Yes     No   

If so, please list:

What products do you currently use on your face?

  soap  cleanser  toner  exfoliator

mask     sunscreen   anti-aging serum   make-up

Brand(s)

Would you describe your skin as normal, oily, dry or combination?
(oily on forehead, nose and chin/normal to dry on cheeks)?

What special needs or areas of concern do you have?

Are you presently under a physician’s care for any current skin condition or other problem?   
Yes       No       

If yes, please explain

4.  Are you pregnant?          Yes       No

5.  Are you taking birth control pills?          Yes     No

     If so, what type?                   

 6. Are you taking Hormone replacement?          Yes     No              

7.  Do you smoke?           Yes      No

8.  Do you often experience stress?          Yes     No            

9. Have you had skin cancer?    Yes   No

Please list any other significant details:

I understand that the services offered are not a substitute for medical care or an in-person consultation.  I also understand that the information herein is to aid the therapist in giving skin care product recommendations and is completely confidential.

In order to best assist you, the therapist may need to contact you with further questions.

Is this okay?      Yes    No

Your preferred method of contact:       Email        Phone

By submitting this form I agree that the above answers provided are true and correct and this serves as my electronic signature.