Desert Botanics

Desert Botanics
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1) Have you had a professional skin care treatment before? If yes, when?
2) What was your favorite part of the treatment?
3) Do you have any special skin concerns/goals pertaining to your face or body? Specify:
4) Have you ever had any chemical peels, laser or microdermabrasion treatments?
In the last month?
5) What skin care/cosmetic products are you currently using?
6) Have you used any hair removal methods in the past six weeks? If yes, what kind?
7) Have you recently had excessive sun exposure/ sun bed treatments?
8) What areas of concern do you have regarding your skin: Please check all that apply:

Breakouts/acneBlackheads/whiteheadsExcessive oil/shineBroken capillariesUneven skin toneSun damage/sun spotsWrinkles/fine linesFlaky/peeling skinDermal redness/ rosaceaDehydrated skinDull/dry skinOther
Medical History
9) Please list any known allergies or skin irritants? Please include ALL food, shellfish, animals, cosmetics, fragrance, pollen, etc
10) Please indicate any medications you are currently taking (including both topical & oral)
11) Have you ever used an acne medication? If so, please specify medication and last use:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products? If yes, describe:
13) Have you experienced Botox, Restylane or Collagen injections in the past three months? If so, describe:
14) Are you pregnant/ planning to become pregnant or currently nursing?
15) Are you undergoing any hormone replacement therapy?
Lifeslyle
16) Exercise habits:
17) Ounces of water consumed daily?
18) Please rate your stress level on a scale of 1-10
19) Are you a smoker?
20) Are you sleeping 6+ hours per night?
21) Are you currently taking any herbs/vitamins or supplements?
No Show/ Cancellation Policy

If you must cancel/reschedule your appointment, please notify Desert Botanics no less than 24 hours prior to your scheduled treatment. Those who fail to show up for scheduled appointments or do not provide proper notice will be assessed a no show fee applicable to 50% of scheduled services.

I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments Ireceive here are voluntary and I release this institution and/or Skin Care Professional from liability & assume full responsibility thereof.
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Medical History

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