Face Reality Treatment

New Acne Client Questionaire
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Birthdate
Age
If you have recently received Botox injections or lip filler treatments, or if you plan to do so, we kindly request that you refrain from scheduling your facial appointment within two weeks following these procedures. This waiting period allows for the Botox and lip fillers to settle properly, ensuring optimal results from both treatments.Performing facials too soon after Botox injections or lip filler treatments may inadvertently interfere with the settling process of these injectables and could potentially impact the outcomes of all treatments involved.*
Initial
How did you hear about The Skin Bar Aesthetics?

Please list your current skincare routine:
Have you had any bad reaction to anything you put on your face? If so, please list in detail
Are you allergic to the following?

SulfurLatexAspirinOther
Please list any known allergies:
Do you smoke?
Do you regularly swim in a chlorinated pool?
Do you use fabric softeners or dryer sheets?
Do you work around chemicals, tars or grease?
Occupation:
Do you work nights?
Are you currently under stress? (new job, job loss, wedding, romantic breakup, school, death of a loved one, graduation, difficult home life, long commute, heavily scheduled, new parent, recently moved, medical condition)
Are you a vegetarian or a vegan?
Do you like to spend time outdoors?
Do you develop cold sores/blisters?
Have you used Accutane (isotretinoin) in the past 6 months?
Women Only: Are you pregnant, trying to become pregnant, or nursing?
Women Only: Are you using a hormonal birth control? If so, please list:

Acne Treatment and Consent:

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 30 to 75 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for home care. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.

Please read and initial the following carefully:
I have not had any chemical peel of any kind 14 days prior to this treatment. I understand that I cannot have any other treatments performed to my face without consulting The Skin Bar Aesthetics.
Initial
I have not had any facial waxing within 7 days of this treatment. I will not get waxing for 7 days following this treatment.
Initial
I have informed The Skin Bar Aesthetics of any topical or oral medications I am using, including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac), Accutane, or antibiotics.
Initial
I agreed I have not been exposed to excessive sun or wind and my skin is not irritated in anyway. I understand my skin cannot be compromised to receive treatments.
Initial
I recognize that the products The Skin Bar Aesthetics recommends are clinical strength active formulas that are designed to treat problematic skin. Tingling sensations are normal with product application but should not be painful. If I experience pain or discomfort, I will contact The Skin Bar Aesthetics.
Initial
I understand I cannot bring my pets or children to my The Skin Bar Aesthetics appointment.
Initial
I agree to The Skin Bar Aesthetics 24 hour rescheduling policy. Any appointment canceled on the day of will incur a 30% charge of the total appointment cost. A no-show will result in a 50% charge of the total service.
Initial
I agree not to pick at my acne, as it may inhibit my progress and treatments.
Initial
I agree to avoid direct sunlight for at least 3 days following treatment.
Initial
I agree to wear SPF 30 everyday.
Initial
I understand that I may experience much visible peeling, flaking, discoloration, or irritation following this treatment. I agree to follow my homecare to help with healing of my skin.
Initial
I understand that controlling acne is best achieved through treatments every two weeks, using homecare as directed, and following all diet and lifestyle recommendations. I understand that without following the suggestions by The Skin Bar Aesthetics, I may not get my desired results.
Initial
I have informed The Skin Bar Aesthetics of all health problems that I am aware of.
Initial
I understand I can exchange or return Face Reality products within 7 days of purchase. Items must be in new condition and unopened to qualify for a full refund. If the item has been opened, The Skin Bar Aesthetics offers 40% store credit as an alternative.
Initial
I content to photographs taken of my for to be used for monitoring treatment progress.
Initial
I agree to the above and content to the treatments performed on me. I agree that I will inform The Skin Bar Aesthetics of any changes to my skin. I agree to follow homecare and post-treatment instructions.
(Yes or No)
Print Name

First NameLast Name
Name of Parent/ Guardian (if under 18)

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Rows	Currently Using	Previously Used
Antibiotics
Accutane
Benzoyl Peroxide
Retin A (Vitamin A/ Retinol)
Tazorac
Differin
Epiduo
Azelex
Avita
Cleocin-T
E-mycin -T
Copaxone
Corticosteroids
Quinine
Steriods
Marijuana
Cocaine/Speed

Rows	Daily	Weekly	A few times a month	Monthly	Never
Fast Food
Processed Food
Salty Snacks
Milk
Yogurt
Cheese
Other Dairy
Whey or Soy
Peanut Butter
Peanuts
Sushi
Kelp/ Seaweed
MIso Soup
Soy
Seafood
Sugary Foods
Alcohol

New Acne Client Questionaire