Medical Skin History

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:*
ex. 555-555-5555
Birthdate:*
ex. 01/05/1960

Skin Care History
When washing my face:*

I use hot waterI use warm waterI use cool or cold water
How often do you use a skin regimen?*

1x per day2x per dayI do not use a regimen
Do you have an aversion to hot or cold tempuratures used on your face?*

YESNO

Preparing for your appointment
Please bring a photo of all of the products you currently use to your appointment, or fill them in below. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will also be suggested Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin.
Current skin care products you use at home. Include brand names and product names. You can upload below a photo of all your products in a single photo.*
Browse Files
Add Photo of All Your Products Cancelof
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 to the skin from 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 treatments I receive here are voluntary and I release Carin McGrath of Skin By Carin from liability and assume full responsibility thereof.*
To cancel an appointment please contact 818.301.9096 or booking@skinbycarin.com at least 24 hours prior to your appointment. Cancellations not made within 24 hours will be charged a no-show fee.*

I understand the cancellation policy. YES or NO
OPTIONAL: I grant permission to Skin By Carin to use photos of my progress for marketing purposes on www.skinbycarinmcgrath.com or other business listing pages such as Instagram.*

YES or NO
Date*

MonthDayYear
Signature or ( Parent Signature for Minors)*
Should be Empty:

Medical & Skin History