Name
*
First Name
Last Name
Date of Birth:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are your main Skin Goals/Concerns?
*
How would you describe your skin type?
*
Oily
Dry
Combination
Sensitive
Please Select all that apply:
*
Currently pregnant
Currently breastfeeding
History of a bleeding disorder
Pacemaker
Diabetes
Current smoker/vaper
Current or history of cancers
Current or recent infection
Coagulation disorders or blood clots
None of the above
*
History of seizures
History of vertigo
Hepatitis or liver disease
Autoimmune disorder
PCOS
High/Low blood pressure
Thyroid disorder
History of herpes simplex/cold sores
None of the above
What medications and/or supplements are you currently taking?
*
Please list any topical, medication, or food allergies
Have you used Accutane in the past 6 months?
*
yes
no
Are you currently on or have you ever used Hydroquinone?
*
Yes
No
Are you currently on birth control? If so, what kind?
*
Are you currently on Hormone Replacement Therapy? If so, what kind?
*
Do you have a history of Eczema, Dermatitis, Psoriasis, or Rosacea. If so, when was the last flare?
*
Any Antibiotic use in the past 30 days?
*
yes
no
Are you currently under the care of a Doctor for any reason?
*
Have you worked with an esthetician before? If so what have you done? I.E: facials, peels, dermaplanes, microneedling, lasers, etc. If so, please estimate the most recent date of service:
*
Please give a brief overview of your current skincare routine/products you use. (if you don't have one just leave blank)
How did you hear about me? (If referred please list their name)
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