Please call to make an appointment before fill out the application.
Name: *Phone: *
Address: *
City: *State: *Zip: *
Email: *
Referred by:Date of Consultation:

Your health
1.Within the last year, have you been under a dermatologist's or other physician's care?YESNO
If yes, please specify
2.Have you had any health problemsin the past or present?YESNO
If yes, please specify
3. List any medications, supplements, vitamins, dinreties, slimming pills, isotretinein, etc., thay you take regularly.
4.Do you smoke?YESNO
5.Do you exercise regularly?YESNO
6.Do you follow a restricted diet?YESNO
7.Do you wear contact lenses?YESNO
8.Do you have metal implants, a pacemaker or body piercing?YESNO
9.Rate your lavel of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress)
10.Do you have any allergies?YESNO
If yes, please specify
11.Do you sumbathe or use taming beds?YESNO
12.Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?YESNO
13.Have you ever experienced claustrophobia?YESNO

Your skin
1.What are your specific concerns / Challenges with your skin?
2.What skin care products are you currently using?
Face: soap, clearser, toner, moisturizer, masque, exfoliate, eye products.
Body: soap, shower gel, scrubs, oil, body moisturizer, depilatory products, seif tanners.
3.Have you ever had chemical peels, microdermabrasion, or amp resurfacing treatments?YESNO
In the last month?YESNO
4.Do you use Retin-A, Renova, Adapalene or any other presscription skin products?YESNO
In the last 3 month?YESNO
5.What skin care products are you currently using?
glycolic acid, lactic acid, any exfoliating scrubs, any hydroxy acid product, Vitamin A derivatives (i.e. Retinol)
6.Do you ever experience these conditions on your skin? flakiness, tightness, obvious dryness
7.What SPF sunscreen do you use on your face?Body?
8.Do you burn easily in moderate sunlight?YESNO
9.Do you have a tendency to redness? YESNO
10.Do you suffer from serious problems? YESNO
11.Do you ever experience burning, itching or stinging sensations on your skin? YESNO

Female Clients only
1.Are you talking oral contraception?YESNO
2.Are you pregnant or trying to become pregnant?YESNO
3.Are you lactating?YESNO
4.Are you currently having or lose for year menstrual?YESNO

Male Clients only
1.Do you have any shaving challenges?YESNO
If yes, please specify

Questions to discuss every visit
1.Have you started my new medication since your last visit?YESNO

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatments.

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