Facial Consultation Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you pregnant or lactating?
Yes
No
Do you wear contact lenses
Yes
No
Do you currently have a sunburned/red face?
Yes
No
Are you in the habit of going to tanning booths?
Yes
No
Do you currently use any depilatories or wax?
Yes
No
Have you had a chemical peel or any type of procedure within the last 14 days?
Yes
No
If yes, what type?
Do you have regular collagen, Botox, or other dermal filler injections?
Yes
No
Have you recently had any laser resurfacing or facial surgery? If yes, when?
Are you currently taking any medications, topical or otherwise? (Tretinoin/Tazorac/Avage/Epiduo/Ziana) If yes, which ones and for how long?
Have you ever undergone Accutane therapy (isotretinoin)
Yes
No
Do you have any allergies or sensitivities?
What is your skin type?
Dry
Oily
Combination
Normal
Sensitive
What brings you in today? Do you have any skin concerns?
For the purpose of documentation, I consent to the taking of before and after photographs. Please note, these will not be used for marketing.
Yes
No
Signature
Submit
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