Date
*
-
Month
-
Day
Year
Date
Patient Name:
*
Age:
*
DOB
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Please enter a valid phone number.
Email:
*
1. Circle all skin concern(s) that you are seeking improvement upon.
*
PIGMENT
AGING
ACNE
ROSACEA
Other
2. How would you describe your skin?
*
DRY
NORMAL
COMBINATION
OILY
ACNE PRONE
3. Are you prone to cold sores?
*
Yes
No
If yes, when was your last outbreak and what medication do you use?
4. Do you have permanent makeup?
*
Yes
No
5. Do you wear contacts?
*
Yes
No
6. Have you recently had facial or body waxing, or used at home depilatories?
*
Yes
No
7. Do you have extended outdoor plans in the next 7 days?
*
Yes
No
8. Do you currently have sunburn or wind burned skin?
*
Yes
No
9. Have you tanned or used self-tanner in the last 7 days?
*
Yes
No
10. Do you plan to participate in vigorous exercise in the next 72 hours?
*
Yes
No
11. Have you had any active skin care treatments in the past 21 days? (Includes physical exfoliants, acids, retinols/retinoids, dermaplaning, lasers, chemical peels, and microneedling)
*
Yes
No
If yes, please describe and provide treatment date?
12. Have you ever had an issue with a skin care product or treatment before?
*
Yes
No
13. List all topical products applied in the last 7 days.
*
Yes
No
14. Have you ever had a chemical peel before? If yes, tell us about the peel and your experience.
*
Yes
No
15. List all prescription medications currently taken and in the past two weeks
*
Yes
No
(NOTE: Patients MUST be off Accutane for 3-6 months prior to peeling)
16. Have you recently undergone any surgery or laser treatments in the area to be treated?
*
Yes
No
If yes, please provide detail.
17. Do you receive injectables? (Botox, fillers)
*
Yes
No
If yes, what date was the last injectable done?
18. Do you have any known allergies or sensitivities?
*
Yes
No
(Please list)
19. Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, etc.)
*
SUBMIT
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