For your safety and comfort please provide sincere, detailed responses.
1. Legal Name
2. Preferred Name
3. Preferred Pronouns
Other Please List
4. Date of Birth
5. Phone Number and Email
6. Mailing Address
7. Preferred Contact Method Mark only one oval.
8. Emergency Contact Name and Phone
9. How did you hear about Retaliation Aesthetics?
10. What genre of music do you find most relaxing? Check all that apply.
Soft melodies with lyrics
I prefer to chat during my treatment
11. What concerns do you have about your skin? Check all that apply.
Pore size or appearance
Discoloration (pigmentation, age spots, redness, blotchiness)
Dryness or Flaky appearance
12. What would you like to achieve with today's treatment?
13. Which of the following describes your skin after a day in the sun? Mark only one oval.
I Burns always, tans never
II Burns always, tans slightly
III Burns moderately, tans gradually
IV Burns seldom. tans always
V Burns rarely, tans deep
VI Burns rarely, deep pigment
14. After washing your skin do you experience any of the following? Check all that apply.
15. Which products are a part of your current skin care routine? Check all that apply.
Exfoliant (physical or mechanical)
16. If you have had a professional facial before were you pleased with the outcome? Mark only one oval.
17. In the past 12 months have you been under the care of a physician or dermatologist for a chronic or acute ailment? Please detail
18. What prescription medications and/or supplements are you currently taking?
19. Please check any conditions you have been diagnosed with Check all that apply.
High Blood Pressure
Heart Attack, Disease, Problem
Epilepsy or other seizure disorder
Herpes including herpes simplex (cold sores)
Blood clots, poor circulation
20. Are you currently pregnant? Mark only one oval.
21. Have you ever had Check all that apply.
22. Have you ever experienced an allergic reaction? Please detail
23. Have you used any of the following in the last 3 months? Check all that apply.
24. Have you ever been prescribed Accutane medication? Mark only one oval.
25. In the last 30 days have you had Check all that apply.
Dermal Filers (Restylane, Juvederm, etc)
26. Do you wear? Check all that apply.
27. Are you currently utilizing Check all that apply.
Hormone Replacement Therapy
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