Contact Information What are your top 3 skin concerns/goals?
Medical History Medical Conditions (check all that apply)
Are you currently taking medication? (if yes, please explain)
Do you use topical prescriptions? (if yes, please explain)
Have you taken antibiotics recently? (if yes, please explain)
Have you been on Accutane or other acne medications? (if yes, please explain)
Do you have any health conditions? (if yes, please explain)
Lifestyle Do you eat or drink any of the following at least 1x a week? (check all that apply)
Are you experiencing any of the following? (check all that apply)
Do you take Ibuprofen, Advil, or pain medication 1x or more a week? (if yes, please explain)
On a scale of 1-10 what is your current stress level?
Skin Assessment Have you had facials, peels, microdermabrasion, or any resurfacing treatments? If so, was it within the last month?
Do you wax your facial skin on a regular basis? If so, when was the last time?
Do you use Retin-A, retinal, or retinol?
Are you using Benzoyl Peroxide?
Do you have any allergies or sensitivities? (if yes, please explain)
Do you have sensitivites to any of the following? (check all that apply)
What is your current skin regimen? (please list brands and products including foundation)
Are you using any exfoliants? (if yes, please explain)
Have you had any of the following procedures? (check all that apply)
Waiver of Liability
I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.
I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.
I do not have active cold sores.
I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.
I understand that it is recommended prior to having a facial infusion to not have used Retin A for 48 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment.
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary, and I release the company and/or skin care professional from liability. Submit
Thanks for submitting! You'll hear from us soon.
%20(1).png)