• DermaLux Skincare. New Client Consultation Form

  • Date*
     - -
  •  -
  • How did you hear about me?*

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any of these hair removal services in the last 30 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?

  • MALE CLIENTS

  • What is your current shaving system? *
  • Do you experience irritation from shaving? *
  • Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not foget to confirm your appointment when you receive your reminder from DermaLux. In the event of cancellations received less than 24 hours prior appointment a cancellation fee equal to the reserved service booking will incur; Saturday cancellations require 48 hour notice, or purchased any voucher will be redeemed. No Shows will be charged 100%*
  • Should be Empty: