Name * First Name Last Name Email * Date of Birth * What brings you in today? * List your top skin concerns or goals Have you had professional skincare treatments before? If yes, what kind and when? Do you experience any of the following? check all that apply Acne Dryness Rosacea Melasma Fine lines/Wrinkles Pigmentation Large pores Sensitive Skin Are you currently pregnant or nursing? Do you have any allergies? Include Skincare Ingredients, Medications, Food, Latex, etc. Do you have any medical conditions we should be aware of? History of cold sores? so we can prevent them during treatment:) Do you have a history of Keloid Scarring, or abnormal wound healing? Are you currently taking an medication or supplements? List all including antiobiotics,steroids,and blood thinners Are you using any topical prescriptions? Retin-A, hydroquinone, tretinoin, steriods Have you ever taken Accutane? If yes, when did you stop How often are you in the sun? Do you wear SPF daily? Have you recently had any cosmetic procedure? Botox,Fillers,Peels, Microneedling,Laser, Waxing etc. Is there anything else your esthetician should know before your appointment? Thank you!
