Consultation Card : Please answer these questions to help us provide the best service for your skin.

1Within the last year, have you had any health problems that have affected or could affect your skin?no yes If yes, please specify:

3 Do you wear contact lenses? 4 Do you have metal implants, a pacemaker or body piercings?

5 Do you have any allergies? If yes, please specify:

6 Do you have sinus problems?

7 Have you ever experienced claustrophobia?

10 Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months? no yes

12 Are you currently using any products that contain the following ingredients? Glycolic AcidLactic Acid any exfoliating scrubs Vitamin A derivatives (i.e., Retinol) Other Hydroxy Acids 14 Please specify if any of the following apply to you: pregnanttrying to become pregnantlactating

13 Have you used a Retin-A, Renova, Adapalene, or any other prescription skin products within the last 3 months?

14 Please Specify 

Pregnant

Trying to Become Pregnant

Lactating

Menstruating

Pre-Menstrual

This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.

I confirm (to my best knowledge) that the answers I have given are correct and that | have not withheld any information that may be relevant to my treatment.

1Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?no yes yes yes yes yes their affiliates and , subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and/or

2 Do you have active cold sores? 3 Have you received Botox or other injectable procedures within the past week? 4 Do you sunbathe or use tanning beds? 5 Do you experience redness, itching, or stinging on your skin? | release and waive any claims against Dermalogica, LLC and

| have received Post-Care instructional sheet.