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Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
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example@example.com
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Date of Birth
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What is your preferred method of communication
Text
Email
Phone
Occasionally we send out newsletters with updates, new services, and exclusive offers. Would you like to be added to our email list?
yes
no
Who may we thank for referring you?
Health Information
Many health conditions and medications can affect your skin. Please fill out the following information so we can give you the best service and outcome.
Do you have any allergies (medicines, cosmetics, environmental, foods)?
Have you been treated for skin cancer?
Yes
No
Have you had any recent surgeries?
Yes
No
Are you currently under the care of a physician or dermatologist at this time ?
Yes
No
If yes, please explain
Have you had any of the following health conditions in the past or presently?
Cancer
Diabetes
Thyroid or hormone imbalance
Auto Immune Disorders
Heart problems
Cold sores
Covid 19 illness or exposure
Active infections
Claustrophobia
Pace maker or other metal implants
Other
Do you smoke?
Yes
No
Are you pregnant, nursing or trying to get pregnant
Yes
No
Are you on birth control?
Yes
No
What is your stress level ? On a scale of 0 to 10 with 0 being no stress at all.
no stress
0
1
2
3
4
5
6
7
8
9
extremely stressed
10
0 is no stress, 10 is extremely stressed
Please list all medications including over the counter
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?
Yes
No
Skin Questionnare
Are you currently using Retin A, prescription or over the counter acne medication, glycolic acid, accutane, or retinals?
Yes
No
If Yes, which one and for how long? When was your last use?
Have you ever had a professional facial before and have a reaction afterward to a product?
Yes
No
If yes, do you know what the product was and how did it affect you?
Please share what your concerns are , such as dryness, oiliness, sun damage..
What skin care products are you currently using? Include brand. You may also take a picture of the front and back of all your products and upload it below.
Upload product photos
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How satisfied are you with the appearance of your skin?
I can't look in the mirror
0
1
2
3
4
5
6
7
8
9
I love my skin and want to keep it that way
10
0 is I can't look in the mirror, 10 is I love my skin and want to keep it that way
Do you currently use any tools on your face at home? Please include anything you use i.e. clarisonic, LED light, jade roller
Photos of skin concerns/problem areas
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Front View
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Right Side
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Left Side
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I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation of the skin from the treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatment and/or products that I receive here are voluntary and I release Citrus Med Spa & Acne Clinic and their staff from liability and assume full responsibility thereof.
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