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Consultation Form!

First and Last name
Address, city, state and zip code
Phone #
Email address
Referrd by
Name as it appears on social media
Have you ever had a facial before?
No
Yes
If so, when was the last time you had a facial?
Do you use RETIN-A, RENOVA, AHA?
No
Yes
If you do use Retin-A, Renova or AHA, Did you used it in the last week?
Ever had a Chemical peel, Laser or a Micodermabrasion? If so which one and ehen was the last treatment you had?
Have you ever used a prescription acne medicine? If so, Which one and when?
What skin care product are you currently using? (Cleanser, Toner, Moist...)
Have you ever had any allergic reaction to any of the following?
Latex
Fragrence
Sunscreen
Benzoyl peroxide
AHAS
Food
Shelfish
Medicine
Cosmetics
Have you ever had any recent tanning bed or sun exposure that changed the color of your skin? If so' please specify
Have you ever had Botox or Collagen injections? If so, please specify
Medical History (please check all that apply)
Asthma
Birth control
Pregnant
Cancer
High blood pressure
Eczema
Diabetic
Epilepsy
Heart condition
Hepatitis
HIV / AIDS
Hypo Thyroid
Plastic surgery
Metal Implants
Seborrhea
Psoriasis
Lupos
When you wake up in the morning how does your skin feels like? (dry, oily or normal)
And 4 hours later?
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