N|M SkinCare Beauty

N|M SkinCare Beauty

Confidential Skin Health Questionnaire
What To Know Before Services

When making an appointment with N|M SkinCare Beauty, it’s important to follow these guidelines to make sure you get the best results from your service. By scheduling an appointment, you are agreeing to these policies.

How Do I Prepare For A Treatment? Make sure to avoid scrubs, AHAs, benzoyl peroxide, retinols, or topical prescriptions for 3 days before your appointment. Also, avoid facial waxing or injectables within a week before your appointment.

What Is Your Cancellation Policy? Please allow 48 hours for cancellations or rescheduling. Failure to do so will result in 100% of the service charge or deduction in series/gift certificate. Failure to cancel or reschedule before 48 hours will result in the card on file being charge 100% of the service charge.

If I’m running late, will I still get the full service? Guests who arrive late are not guaranteed a full service. We will do our best to accommodate guests. However, if time does not allow, the service will be cut short by the time late. If the guest is too late to receive the service, they are responsible for full price of the service.

Could I have any allergic reaction to any products used during during a service? If you have any allergies, this should be communicated before arriving for your appointment.

How can I pay? N|M SkinCare Beauty accepts all major credit cards. While N|M SkinCare Beauty accepts cash, change is not kept on location, therefore cannot be given.

What to AVOID after a Facial? Sauna or steam room. Wax, shave, or have laser hair removal. Spend time in the sun without proper SPF protection. Avoid sunbathing or getting sunburnt. Pick and pop pimples (hands off!!!). Apply harsh and potentially irritating at-home peels or retinol treatments.

What to AVOID after a Chemical Peel? Sauna or steam room. Wax, shave, or have laser hair removal. Avoid sun for at least 5-7 days. Drink excessive alcohol (delays healing process). Do not exfoliate (avoid for 5-7 days or until fully healed). Do not pick/pull/rub the skin during the peeling process. Avoid strenuous exercise, heat, or sweating. **Always wear sunscreen (SPF 30+)**

What to AVOID after a Microneedling? Sauna or steam room. Wax, shave, or have laser hair removal. Avoid sun for at least 5-7 days. Do not take ibuprofen. Avoid strenuous exercise, heat, or sweating.

N|M SkinCare Beauty

Confidential Skin Health Questionnaire
Name*

First Name Last Name
Occupation*
Birthday*

MonthDay Year
Date
Email*
example@example.com
Phone Number*

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referred by?
Google, Instagram, Facebook, TikTok?
Expectations and History
Which conditions would you like to improve? (Select all that apply)*

Acne ScarringAcneAge SpotsEnlarged PoresFine Lines & WrinklesHyperpigmentation (Dark Spots)Broken CapillariesStretch MarksSurgical/Facial ScarsSun DamageDrynessDehydrationEczemaPsoriasisMelasmaSensitivityRosacea
How would you describe your skin?*

NormalDryOilyT-Zone (Oily) / CombinationSensitiveSun DamagedDehydrated
How would you rate your skin when exposed to UVA/UVB rays?*

I. Always burns - Never tansII. Always burns easily - Tans SlightlyIII. Burns moderately - Tans GraduallyIV. Seldom burn - Always Tans WellV. Rarely Burns - Deep TanVI. Never Burns - Deeply Pigmented
Ethnic Background*

English / IrishNative AmericanAfrican AmericanGerman / DutchHispanicItalian / MediterraneanAsianRussianPolish / Hungarian
Eye Color*

BlueGreenHazelGrayLight BrownDark Brown
Natural Hair Color*

BlondeRedBlackWhiteLight BrownGray / SilverMedium BrownDark Brown
Skin Tone*

Pale / WhiteLightLight OliveMedium OliveDark OliveBrownBlackReddish / Freckles
Do you ever experience flakiness, tightness, redness, or excessive oil shine during the day? (Select all that apply)*

FlakinessTightnessRednessExcessive oily shine during dayNone of the above
What is your current skin regimen? (Choose all that apply)*

Soap & Water onlyOil-Based CleanserCleanserTonerVitamin C SerumExfoliants (AHA's) - Lactic, Glycolic, Mandelic, Citric, Malic (BHA’s) - Salycilic AcidMasqueEye CreamMoisturizerRetinol (Vitamin A)Sunscreen 30+ (every day)
Are you exposed to chemicals, oils, or other caustic substances that may aggravate your skin?*

YesNo
If yes, what are they?
Do you blush easily?*

YesNo
If yes, what are the contributing factors?

EmotionsFoodsTemperature Changes (heat, steam, shower, exercising)None of the above
Have you ever had any of the following: (Select all that apply)*

Chemical PeelsMicrodermabrasionFacial SurgeryCosmetic SurgeryCollagen InjectionsLaser ResurfacingBody TreatmentsNatural Peels (Enzyme Peels)None of the above
Do you sunbathe or use a tanning bed?*

YesNo
Have you had Botox or Fillers in the past 2 weeks? [You must wait at least 2 weeks before a Microneedling Treatment]

YesNo
Have you had a Chemical Peel in the past 2-weeks?

YesNo
Have you had a Laser Resurfacing/Laser Hair Removal Treatment in the past month? [You must wait at least 2 weeks before getting a Resurfacing (exfoliating) Treatment]

YesNo
Have you taken any antibiotics in the past 2 weeks? *
If yes, what?
Are you under treatment for any current skin condition?*

YesNo
If yes, what?
Please explain in detail
Do you bruise easily?*

YesNo
Do you get sores/blisters (Herpes Zoster/Shingles)? [Please be informed that Chemical Peels can trigger outbreaks]*

YesNo
What medications/hormone replacement/vitamins do you presently take?
List everything you take please!
Have you ever used? (Select all that apply)*

AccutaneRetin-ARenovaTopical AntibioticsDifferinTazaracHydroquinoneAHA’s (Alpha-Hydroxy-Acids) - [Lactic, Glycolic, Mandelic, Malic, Tartaric, Citric Acid]BHA’s (Beta-Hydroxy-Acids) - [Salicylic Acid]None of the aboveBenzoyl Peroxide
If you have used any of the above ingredients, please indicate when and for how long you have used them:
Any personal or family history of skin cancer?*

YesNo
If yes, provide detail:
How would you describe your overall health?*

ExcellentGoodFairPoor
Have you had any of the following, past or present?

AcneAllergiesArthritis or BursitisBreast ImplantCancerCataractsLow-CholesterolHigh-CholesterolClaustrophobicDiabetesDiarrheaConstipationEczemaEpilepsyHay FeverHeadachesHeart Disease/ConditionsHepatitisHIV/AIDSInfectionsLupusMenopausalMetal ImplantsPace MakerPhlebitisSerious InjurySleep ProblemsLow-ThyroidHigh-ThyroidVaricose VeinsHormonal ImbalancePsoriasisVitiligoHirsutismIrregular Blood Pressure
Do you smoke?*

YesNo
Do you wear contact lenses? [As a precaution, it's best to come to the spa without your contact lenses in. Products used during your facial along with the steam could irritate your eyes]*

Yes, I will remove my contact lenses before my treatment to avoid any irritation/pinkeye etc.No
Do you?

Have a PacemakerHave Metal ImplantsHave piercings/earrings/necklaces (remove before facial)
Have you ever had a reaction to (Select all that apply)

CosmeticsLicodaineSunscreenMetalsMedicationsFoodFragranceAirborne particlesAspirinNutsLatexDairyCitrusApplesGrapesAloe VeraHyaluronic AcidVitamin CEssential Oils (Lavender, Lemongrass, Peppermint, Eucalyptus, etc.)BHA: Salicylic AcidAHA: Glycolic AcidAHA: Lactic AcidTCA

FOR WOMEN ONLY: (scroll down for MEN questions)

	YES	NO
Oral contraceptives?
Are you trying to get pregnant?
Are you currently pregnant?
Do you experience hormone imbalances?
Are you undergoing hormone replacement?
Any menopause issues
Are you breastfeeding?

FOR MEN ONLY:

Electric Shaver Razor

Do you shave with

	Electric Shaver	Razor
Do you shave with

FOR MEN ONLY:

	YES	NO
Do you experience skin breakouts?
Do you have ingrown hair?

Lifestyle & Diet

Answer to the best of your knowledge

	YES	NO
Do you normally sleep well?
Have you ever had claustrophobia?
Do you exercise regularly?]
Do you follow a special diet?

What do you consume on a daily basis? (Select all that apply)

ProteinComplex CarbohydratesVegetables & SaladsFruit
Is your stress level*

HighMediumLow
Do you have food intolerances?*

YesNo
What food intolerances do you have? (Leave blank if none)
How many cups glasses of water do you consume daily?*
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?*

None1 cup2-3 cups4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you?*

YesNo
Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.
Informed Consent Release

Please Read the Information Below
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I understand that if I pick at the new skin or rub it it may prolong the healing process and possibly cause pigmentation/skin discoloration.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that by signing this I hereby to give consent to NM SkinCare Beauty to photograph, film, and/or videotape and then use, reproduce, and publish them for marketing purposes.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments
Signature*

Clear
Polices
I have read and understand all of the foregoing information
1. We require 48-hours notice for cancellations. If you do not cancel within 48-hours you will charged 50% of the service. Cancellation for Monday must be phoned on the Friday before.

2. If you are not satisified with your service or products, please contact your skin care professional within 24-hours after your appoinment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.
Date*

MonthDay Year
Date
Signature*

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N|M SkinCare Beauty

What To Know Before Services

N|M SkinCare Beauty

Expectations and History

Lifestyle & Diet

Informed Consent Release

Polices