Novy Skin In-Take Form

By Raya

look better | feel better
CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE
Today's Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Street
Apt. #
City
State
Zip
Phone
E Mail
example@example.com
Dermatologist/physician
Dermatologist/physician Phone
Emergency Contact Name
Emergency Contact Phone
Referred by

Friend Google YELP Instagram Facebook Gift Card Other
1. What special areas of concern do you have?
Expectations and History
2. Which conditions would you like to improve?

Acne scarring Hyperpigmentation Acne Broken capillaries Age spots Stretch Marks Enlarged Pores Surgical/facial scars Fine lines & wrinkles Other
3. How would you describe your skin?

Normal Dry Oily Combination Sensitive Sun Damaged
4. How would you rate your skin?

I. Always burns - Never tans II. Always burns easily - Tans slightly III. Burns moderately - Tans gradually IV. Sometimes burns - Always tans well V. Rarely burns - Deep tan VI. Never burns - Deeply pigmented
5. Do you ever experience

Flakiness Tightness Redness Excessive oily shine during day
6. What is your present skin regimen?

Soap & water only Cleanser Toner Mask Moisturizer Exfoliation Sun Block every day Other
7. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?

Yes No
If yes, what are they?
8. Do you

Sun bathe Use a tanning bed
How often do you use a tanning bed?
9. Have you ever had

Peels Microdermabrasion Facial surgery Cosmetic Surgery Botox Collagen Injections Laser resurfacing None of the above
How recently was your treatment
10. Are you under treatment for any current skin condition?

Yes No
If yes, what?
11. Does your skin heal as

Scars Fast Pigments I don't know
12. Do you get sores/blisters (Herpes Zoster/Shingles)?

Yes No
13. What medications/hormone replacement/vitamins do you presently take ?
14. Have you ever used

Renova Retin-A Accutane Differin Topical Antibiotics Tazarac Hydroquinone Alpha Hydroxy Acids None of the above
If yes, when and for how long?
15. Any personal or family history of skin cancer?

No Yes
16. Have you had any of the following, past or present?

Allergies Claustrophobic Diabetes Eczema Epilepsy Heart Disease/Conditions Hepatitis HIV/AIDS Lupus Metal Implants Pace Maker Smoking Contact Lenses Metal In The Body None of the above
If YES on allergies, please specify
17. Have you ever had a reaction to

Cosmetics Metals Medication Food Fragrance Airborne particles Other
18. Please select all that apply

Oral contraceptives Pregnant/Trying to get pregnant Experience hormone imbalances Food intolerances Stressed out
19. Novy Skin would like your permission to take and use images/video to showcase extraordinary before and after results on our social media platforms, website and other marketing platforms.

I give my permission I do NOT give my permission
I, name do fully understand all the questions above and answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. I n the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.
I release and hold harmless the skin care professional Raisa Novik, Novy Skin LLC, and the staff harmless from any liability for adverse reactions that may result from this treatment.

1. We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before.

2. If you are not satisfied with your service or products, please contact your skin care professional within 24- hours after your appointment 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.

I have read and understood all of the foregoing information
Client Signature

Clear
Date

Month Day Year
Date
Circadia by Dr. Pugliese, Inc.
Edited by Novy Skin LLC
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By Raya

Expectations and History