Skin Analaysis

Skin Analaysis
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Please list your emergency contact NAME*andPHONE NUMBER*
Your occupation: blanks*
Who referred you? blanks*
Expectations & History
Which conditions would you like to improve? *

Acne Acne Scarring Age spots Enlarged pores Fine lines & wrinkles Hyperpigmentation Broken capillaries Stretch marks Dryness Redness Texture Oiliness Other
If other, please explain.
Have you ever had a facial in the past? *

Yes No
How was your experience?
How would you describe your skin? *

Normal Dry Oily Combination Sensitive Sun Damaged
Do you ever experience: *

Flakiness Redness Tightness Excessive oily shine N/A
What is your current skin regimen? *

Soap & water only Moisturizer Cleanser Toner Serum Exfoliant Sunscreen Daily Other
Please list the products you currently use: *
Do you: *

Sun Bathe Use a tanning bed N/A
Have you ever had: *

Peels Microdermabrasion Facial Surgery Cosmetic Surgery Botox Collagen Injections Laser resurfacing Microneedling Cosmetic tattoos or Permanent makeup None of the above
How recent was your last Botox treatment?

Month Day Year
Date
Are you currently under treatment for any skin condition? *

Yes No
If yes, please explain
Do you bruise easily? *

Yes No
Please list all medications, supplements, and vitamins you are currently taking *
Have you ever used: *

Accutane Retin-A Renova Differin Topical Antibiotics Hydroquinone Aha's Bha's None of the above
When, and for how long? (Type N/A if not applicable.) *
Any personal or family history of skin cancer *

Yes No
Do you currently or have you had any of the following? *

Acne Allergies Arthritis High Blood Pressure Low Blood Pressure Cancer Claustrophobia Diabetes Eczema Epilepsy Hay Fever Heart Disease Infections Lupus Menopausal Pace Maker N/A
Do you smoke or vape? *

Yes No
Are you pregnant or trying to get pregnant? *

Yes No
Are you taking hormone replacements? *

Yes No
Do you experience hormonal imbalance *

Yes No
How many glasses of water do you drink a day? *
What is your budget per service and home care products, if any? *

Less than $100 Less than $250 No Limit
Photo /Video release *

I give Helium Salon permission to use photos of my skin progress for marketing purposes on www.heliumsalon.com and other social media accounts. I do not give Helium Salon permission to use photos of my skin progress for marketing purposes on www.heliumsalon.com and other social media accounts.
Informed Consent
I blanks*, do fully understand all of the questions above and have 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 regiment if deemed necessary. I am also aware that individual results are dependent on my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my abilities so that I may obtain maximum effectiveness. In 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 professionals, Helium Salon, and the staff from any liability for adverse reaction that may result from this treatment.
Policies

We require 24-hours notice for all cancellations. Cancellations with less than 24-hours notice may result in a charge of 50% of all services booked. Arriving 15 minutes or more late late to your service may result in cancellation.
I have read and understand all of the above information. *

Clear
Date *

Month Day Year
Date
Should be Empty:

Skin Analaysis

Expectations & History

Informed Consent

Policies