PURE SKIN AND AESTHETICS SKIN CONSULTATION

THANK YOU SO MUCH FOR CHOOSING PURE SKIN AND AESTHETICS FOR YOUR SKINCARE NEEDS!

Here we strive on safe skin practices through education and transparency. We ask that you answer these questions to the best of your ability so that we may provide you with he most effective results!

This consultation card is used to assess your unique skincare needs. We will keep this information confidential and will only disclose it to:

1) The Lead Aesthetician (Kayla)

2) Our product supplier or manufacturer (in the event of a reaction).

Your information will not be shared with anyone else, except as required by law, and it will never be sold.

Name*

First NameLast Name

Phone Number*

Date of Birth*

MM/DD/YYYY

Within the last year, have you been under a dermatologist’s or other physician’s care?*

If yes, please specify

Have you has any health problems in the past or present?*

If yes, please specify

3. List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:

Do you smoke? (Tobacco, Marijuana, Vapes)

Do you follow a strict diet?

If yes, please specify

Do you wear contact lenses?

Do you have metal implants, a pacemaker or body piercings?*

If yes, please specify

Your level of stress (1-5 being low, 5-10 being high)

Do you have any allergies? (Latex, Fruits, Oils, Aspirin, Fragrances, etc.)*

If yes, please specify

Do you sunbathe or use tanning beds?

How many glasses of water do you drink daily? (8oz. per glass)

Do you drink more than 4 caffeinated beverages daily? (Over 400mg)

Have you ever experienced claustrophobia?

Image Checkboxes*

What are your specific concerns or challenges with your skin?

Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?*

Have you waxed your face in the last 3 days?*

Have you used Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?*

If yes, please specify

Have you taken isotretinoin (Accutane) within the last 6-12 months?*

Are you currently using any products that contain the following ingredients? Select all that apply.*

Do you ever experience these conditions? Select all that apply.*

FlakinessTightnessRednessNon of the above

Do you use SPF on your face?*

Do you use SPF on your body?*

Do you burn easily in moderate sunlight?*

Have you had any direct sun exposure within the last 48 hours?*

If yes, please specify

Do you have a tendency to redness?

Are you prone to cold sores or fever blisters?

Are you currently experiencing a breakout?*

Do you ever experience burning, itching, or stinging sensations on your skin?

Are you taking oral contraception?*

Are you pregnant or trying?

Are you Lactating?

Are you currently menstruating or due to?

What skin care products are you currently using? Please specify to the best of your ability which brand and product. If inapplicable, please type N/A.*

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms.*

I agree

Add any additional notes here:

Please take 3 photos of your skin in natural lighting (The sun or forward lighting)

____________________

Take Photo*

Signature

PURE SKIN AND AESTHETICS SKIN CONSULTATION

OVERALL HEALTH

YOUR SKIN