Patient Consultation Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Date of Birth
MM/DD/YYYY
1. Are you pregnant or lactating?
Please Select
Yes
No
Please consult with your obstetrician. Only the Oxygenating Trio or Detox Gel Deep Pore Treatment is appropriate.
2. Do you smoke or use tobacco?
Please Select
Yes
No
3. Do you wear contact lenses?
Please Select
Yes
No
Remove contacts if eyes are sensitive or if having microdermabrasion
4. Do you have permanent makeup?
Please Select
Yes
No
If yes, please specify what areas to the face
5. Do you currently use or receive dipilatories or waxing?
Please Select
Yes
No
Discontinue use five days pre- and post-treatment
6. Do you have a sunburn/wind burn/red face?
Please Select
Yes
No
If yes, please specify
7. Are you in the habit of going to tanning booths?
Please Select
Yes
No
if within the past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.
8. Are you applying any topical medications at this time?
Please Select
Yes
No
High percentages of certain ingredients may increase sensitivity
If yes, which ones
9. Are you currently using any topical Retinoid prescriptions? (tretinoin, Rein-A, isotretinoin, Accutane, Renova, Differin, Tazorac, Avage, EpiDuo, Ziana)
Please Select
Yes
No
Discontinue use five days before and after treatment. Consult your physician before discontinuing use of any prescription.
If yes, what strength and for how long?
10. Are you currently undergoing isotretinoin therapy (Accutane)?
Please Select
Yes
No
Those who are currently undergoing isotretinoin therapy (accutane) should be directed to their dispensing physician.
If yes, for how long?
11. Have you had a chemical peel, or any type of procedure with a medical device?
Please Select
Yes
No
If yes, within the last 14 days?
Please Select
Yes
No
12. Do you have regular collagen, Botox or other dermal filler injections?
Please Select
Yes
No
Peels should precede or follow injections y two days to prevent movement of the filler or stinging at the injection site
13. Have you recently had facial surgery?
Please Select
Yes
No
If yes, describe and how long ago?
14 Have you recently had laser resurfacing?
Please Select
Flakiness
Tightness
Obvious Dryness
No
If yes, when and what type?
15. Do you develop cold sores or fever blisters?
Please Select
Yes
No
If yes, when was your last breakout?
16. Are you allergic/sensitive to? Select all that apply.
Milk
Apples
Citrus
Grapes
Aloe Vera
Aspirin
Perfumes
Latex
Hydroquinone
Mushrooms
If any other allergies, please specify what
17. Are you sensitive to alcohol-based products?
Please Select
Yes
No
18. Have you ever used any other products that caused a bad reaction?
Please Select
Yes
No
If yes, please specify
19. Are you taking any medications at this time? (antibiotics may. increase sensitivity)?
Please Select
Yes
No
If yes, please specify
20. Do you suffer from sinus problems?
Please Select
Yes
No
21. Do you consider your skin.
Sensitive
Resilient
Unsure
22. Describe your skin.
Normal
Dry
T-Zone/Combination
Thick
Thin
Saggy
Firm
oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
lorid
Roacea
Eczema
Freckled
Sun-damaged
Mesasma
Hyperpigmentation
Perfume-stained
Hypopigmentation
Uneven/blotchy
Mature
Wrinkled
Patchy dryness
Sallow
Psoriasis
Dehydrated/lacking moisture
Asphyxiated
Telangiectasia/broken surface capillaries
23. What are the changes you'd most like to see in your skin?
24. What products are you currently using?
25. What is your regime?
I confirm (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 also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms.
I agree
Add any additional notes here:
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