Skin Health Questionnaire
*Required to be submitted prior to your first appointment.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Emergency contact name and number
*
How did you hear about AfterGlo Esthetics?
*
What is your main skin concern?
*
List any current and/or previous medical history AND any surgical procedures (ex. cancer, heart condition, etc.):
List any over the counter or prescription medications you are currently taking:
List any allergies or sensitivities you may have:
List any prescribed skin medication or topical cream you are currently using:
Are you currently pregnant or planning to be in the near future?
*
Please Select
Yes
No
Please list your full current skincare routine:
Do you wear SPF daily?
*
Please Select
Yes
No
Is your skin...
*
Oily/Acne-prone
Dry
Combination
Sensitive
Normal
Have you ever been treated for a skin condition by a dermatologist or esthetician?
Do you consent to photos or videos of your facial treatment being taken? (To track progress and/or marketing purposes)
*
Please Select
Yes
No
Signature
*
I hereby authorize and consent Monica Glover to perform my scheduled skin treatment
Submit
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