Full Name:
*
DOB
*
-
Month
-
Day
Year
Date
Phone Number:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail Address:
*
example@example.com
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
-
Area Code
Phone Number
What are your top 2 skin concerns or goals for today's visit?
*
How would you describe your skin? (check all that apply)
*
NORMAL/COMBO
OILY
SENSITIVE
DRY
MILD ACNE
MODERATE ACNE
MATURE & AGING
ROSACEA
HYPERPIGMENTATION/MELASMA
DEHYDRATED
ENLARGED PORES
ACNE SCARRING
UNEVEN SKIN TONE
Please list all skincare products you currently use (cleanser, toner, serums, retinol, exfoliants, SPF, prescriptions)
*
Do you wear makeup regularly? If yes, please list foundation, concealer, powder, or mineral makeup brands.
*
Does your job and/or lifestyle require that you work/play outdoors?
*
YES
NO
If yes, how much time outdoors?
*
Do you wear sunscreen daily?
*
YES
NO
SOMETIMES
Do you have any allergies or sensitivities?
*
Have you ever experienced a reaction to any of the following?
*
Rows
YES
NO
COSMETICS
MEDICINE
IODINE (SHELLFISH)
LATEX
POLLEN
FOOD/FRUIT
ANIMALS
FRAGRANCE
ALPHA HYDROXY ACIDS
SUNSCREENS
ASPIRIN
SULFUR
Do you have any of the below health issues?
*
Rows
YES
NO
CANCER
CIRCULATORY ISSUES
ARTHRITIS
DIABETES
PSORIASIS
COLD SORES
CHEMOTHERAPY
HIGH BLOOD PRESSURE
THYROID
RECENT SURGERIES (within 6 months)
ECZEMA
AUTOIMMUNE DISEASE
LUPUS
SKIN CANCER HISTORY
HORMONAL IMBALANCE
THYROID
PREGNANT
LACTATING
PLANNING TO BECOME PREGNANT
Are you currently using any of the following medications or active skincare ingredients? (Check all that apply)
RETIN-A/TRETINOIN
RETINOL PRODUCTS
ADAPALENE (Differin)
BENZOYL PEROXIDE
SALICYLIC ACID
GLYCOLIC ACID
LACTIC ACID
HYDROQUINONE
ACCUTANE (within the last 6 months)
STEROID MEDICATIONS
ORAL ANTIBIOTICS
TOPICAL ANTIBIOTICS
NONE OF THE ABOVE
Have you received any of the following within the last 30 days? (Check all that apply)
CHEMICAL PEEL
MICRONEEDLING
LASER TREATMENT
IPL/PHOTOFACIAL
BOTOX
DERMAL FILLERS
NONE OF THE ABOVE
Birth Control?
*
YES
NO
N/A
I give permission for Viso Bello Spa to use before-and-after photos for educational and marketing purposes. My identity will not be disclosed without additional consent.
Initial here
By signing below, I confirm that the information provided is accurate and that I consent to today’s treatment.
*
Date
*
-
Month
-
Day
Year
Date
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