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Acne Client Agreement Form

Remember:

  • We must update your home care routine on a regular basis to keep your progress to clear skin moving forward.
  • If we do not change your homecare routine often enough, your skin will adapt to the regimen and stop responding (in other words, you wont get clear).
  • Every time we strengthen your homecare routine, we run the risk of drying and/or irritating your skin. You will need to communicate that to us if that happens as soon as possible.

This is why close communication with us is key in getting you clear in the fastest possible way.

First Guest's Name

First Name*

Last Name*

Phone*
First Guest's Age Acknowledgment*
First Guest's Date of Birth*
I certify that I am 18 years of age or older
First Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
First Guest's Signature*
Second Guest's Name

First Name*

Last Name*
Second Guest's Date of Birth*
Second Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Third Guest's Name

First Name*

Last Name*
Third Guest's Date of Birth*
Third Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Fourth Guest's Name

First Name*

Last Name*
Fourth Guest's Date of Birth*
Fourth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Fifth Guest's Name

First Name*

Last Name*
Fifth Guest's Date of Birth*
Fifth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Sixth Guest's Name

First Name*

Last Name*
Sixth Guest's Date of Birth*
Sixth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Seventh Guest's Name

First Name*

Last Name*
Seventh Guest's Date of Birth*
Seventh Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Eighth Guest's Name

First Name*

Last Name*
Eighth Guest's Date of Birth*
Eighth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Ninth Guest's Name

First Name*

Last Name*
Ninth Guest's Date of Birth*
Ninth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Tenth Guest's Name

First Name*

Last Name*
Tenth Guest's Date of Birth*
Tenth Guest's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Parent or Guardian's Email Address

Email*

Confirm Email*
CLIENT REQUIREMENTS: PLEASE READ CAREFULLY AND INITIAL

Ideally, we want to see you every two weeks for an acne treatment while we are getting you clear (typically 3 months). If, for some reason, if I cannot make it in every two weeks, I agree to call or email my skincare professional so we can strengthen your home care regimen. *

I agree to contact My skincare professional immediately if I have adverse reactions to products, I feel burning and/or stinging with any product, I get a rash and/or my skin becomes very dry and irritated before my next appointment. *

I will not use any other products that have not been approved by my skincare professional while I am on their regimen. *

I will not change the regimen given to me by my skincare professional without notifying or consulting with them first. *

I will not run out of product while working with my skincare professional. When you stop using products (or run out) acne will start forming inside the pores and you will see it about a month later. *

I will not have other skin care treatments while I am being treated by my skincare professional *

I will inform my skincare professional of any medications/drugs that I start taking while on their regimen. *

I will use my sunscreen every morning, regardless of whether or not I will be going outside. The sunscreen will help to keep your skin moisturized. Without it, your skin will get too dry. *

I will inform my skincare professional if I elect to do any laser treatments or waxing for hair removal. *

(For women) - I will inform my skincare professional if I get pregnant.

I will abide by all dietary restrictions *

I will check all products of pore clogging ingredients before using. *

I understand in this process breakouts will come and go but I trust the process. *

I understand this is not a quick fix and this program is a minimum of 12-16 week commitment. *

I am excited to get clear and will be diligent with communication, homecare, and treatments *
ACNE TREATMENT CONSENT FORM

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums and extractions.  Treatments take approximately 20 to 45 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for the home care regimen.  Implements and equipment used in all this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations. 

IMPORTANT: PLEASE READ CAREFULLY AND INTIAL



I consent to the professionally recommended acne treatments, facials, and/or chemical peels performed on me by a licensed aesthetician. *

I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way. *

I have not had any other chemical peel of any kind, within 14 days of this treatment. *

I have not had any facial waxing, within seven days of this treatment. *

I have informed the clinic of all health problems of which I am aware. *

I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane. *

I understand that controlling acne/problem skin is best achieved through a series of recommended treatments and compliance to the home care product program recommended by a Spa Kingston certified Aesthetician. *

I understand that I will probably not experience much visible peeling, flaking, discoloration or irritation following this procedure if I follow my homecare instructions carefully. *
CHEMICAL PEEL CONSENT: PLEASE READ CAREFULLY AND SIGN

Do NOT use topical prescriptions, abrasive scrubs or exfoliants 7 days post peel.

No prolonged sun exposure 2 weeks post peel.

Sun protection of SPF 30-45 is to be applied every two hours when in direct sunlight.

I am currently not using any medications that are contraindicated to receiving a chemical peel. i.e. ACCUTANE, tretinoin, Retin-A, Renova, Differin, Tazorac, Avage, EpiDuo, Ziana, and high percentage AHA & BHA products.

Superficial to medium depth chemical peels are topical exfoliants applied to the skin to soften the dead skin layer and stimulate cell turnover restoring the skin to a more youthful appearance.

Many skin conditions can be improved when receiving a series of peels. Fine lines softened, dull skin is more radiant, rough & uneven skin becomes smoother. Sun damaged skin or hyperpigmented skin becomes more even. Acne scarring can soften.

I understand that anytime the skin barrier is compromised; there is a small risk of infection. I will contact my Aesthetician immediately should this happen.

I understand that following the treatment my skin may have slight or extreme redness, swelling, stinging, itchy, tenderness, dry or flaking skin.

I UNDERSTAND THAT I AM NOT TO PICK THE FLAKING SKIN AS THIS COULD CAUSE UNWANTED PIGMENTATION.

Most side effects will gradually diminish over time as healing may take several days or longer. I know I can NOT do strenuous exercise, swimming, or be in hot tubs, hot bath tubs, saunas or steam rooms for 24 hours of treatment time.

The chemical peel treatment has been fully explained and any questions or concerns that I have, have been addressed.

I acknowledge that no guarantee has been given to me as to the condition of the complexion, pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual's unique reactions.

I understand that no specific results are guaranteed.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE ABOVE INFORMATION AND THEREBY CONSENT AND AGREE TO THE TREATMENT WITH ITS ASSOCIATED RISK. I HEREBY CONSENT TO RECEIVE A CHEMICAL PEEL.


POST-TREATMENT PROTOCOL WARNINGS: PLEASE READ CAREFULLY AND INITIAL

Avoid direct sunlight for at least 7 days following a treatment *

Use of sunblock protection of at least a SPF 30 is necessary following all treatments. *

Do NOT pick your skin following a treatment *
PRODUCT RETURN GUIDELINES: PLEASE READ CAREFULLY AND INITIAL

Face Reality Skin Care products are clinical-strength active formulas designed to treat problem skin conditions. Tingling sensations are normal with product application but should not be painful. If you are experiencing stinging and irritation with any product, stop using the product and call your esthetician for further instruction. We have a no return policy. *
RESCHEDULING GUIDELINES: PLEASE READ CAREFULLY AND INITIAL

A 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but we reserve the right to charge a $25 fee for "no show" appointments or 50% of treatment price if contacted but not within a 24-hour notice. *
Photograph Consent
I consent to photographs taken of my face to be used for monitoring treatment progress.*
No
Yes

I hereby agree to all of the above and agree to have this treatment be performed on me. I further agree to follow all post-treatment care instructions as I am directed
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Occupation: *

Ethnicity

What results would you like to achieve with our work?

YOUR HEALTH

Within the last year, have you been under a dermatologist care?*
No
Yes

Dermatologist name:
Within the last nine months, have you undergone any surgery?*
No
Yes

If yes, please specify
Do you have or have had in the past any of these health problems?
Anemia
Asthma
Claustrophobia
Cold Sores
Diabetes
Epilepsy
Heart Problems
Herpes
HIV Positive
Hormone Imbalance
Hypertension
Hysterectomy
Lupus
Raynaud's
Sinus Problems
Spinal Injury
Systemic Disease
Thyroid Condition
Varicose Veins

Other

List any medications, supplements, vitamins, diuretics, slimming pills, etc. that you take regularly:
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
What is your stress level?*

ALLERGY

Do you have an ALLERGY or have you had a reaction to any of the following?
animals
ASPIRIN
cosmetics
essential oils
food
fragrance
fruit
hydroxy acids (i.e. glycol, salicylic)
iodine
medicine
pollen
shellfish
other
sunscreens

Other/Specify

YOUR SKIN

Describe your skin type:*
Do you currently use waxing or depilatories?*
No
Yes
Are you in the habit of going to tanning booths?*
No
Yes

If yes, how often?
Do you have any special areas of concern pertaining to your face?*
No
Yes

If yes, please specify
What skin products are you currently using?
soap
cleanser
toner/astringent
moisturizer
facial masks
exfoliator
eye care
sunscreen
serums
other

What make-up and hair products are you currently using?
Have you ever experienced acne breakouts?*
Affected areas:
face
chest
back
upper arms

other

EXFOLIATION AND BLEACHING HISTORY

Have you ever had a facial, chemical peel, laser, microdermabrasion or any resurfacing treatment?*
No
Yes

If yes, specify when:
Have you ever had injectables?
Botox
Juvederm
Restylane
Radiesse

other
Do you use ACCUTANE, Retin-A, Renova, Trentinoin, Isotrentinoin, Differin, Tazorac, Avage, EpiDuo, or Ziana?*
No
Yes

What strength?

For how long?
Do you use any topical medications?*
No
Yes

If yes, specify

For how long?
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid exfoliating scrubs
Hydroxy acid products
Sulfur
Vitamin A derivatives (i.e. Retinol, Retin-A, etc...)
Cortisone
Cleocin-T

Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or Over-the-counter product? If yes, specify:
Did you experience an allergic reaction to the bleach or fade cream?*
No
Yes
Are you using any topical medication that cause you to peel?*
No
Yes

If yes, product name:

MOISTURE / HYDRATION


How much water do you consume daily?

How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?
flakiness
tightness
dryness

OIL SECRETION

Do you ever experience oily shine during the day?*
No
Yes
Occasionally

If yes, when?

NERVE ACTIVITY

Do you drink caffeinated beverages (coffee, tea, soft drinks)*
No
Yes
Occasionally
What is you pain threshold?*

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?*
No
Yes
Occasionally
Do you have a tendency to redness?*
No
Yes

FEMALE GUESTS ONLY

Are you taking oral contraception?*
No
Yes
Do you experience PMS breakouts?*
No
Yes
Occasionally
Are you pregnant or trying to become pregnant?*
No
Yes
Are you lactating?*
No
Yes
Do you experience ingrown hairs?*
No
Yes
Occasionally
If so, where are they located?
chin
chest
face
Are you taking HRT or any hormone balancing products?*
No
Yes

MALE GUESTS ONLY

What is your current shaving system?
single edge razor
electric/rotary
clipping/trimming
I do not shave
Direction of stroke?

How often?

What shaving products do you currently use?
Do you experience razor bumps/ingrown hairs?*
No
Yes
Occasionally
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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