Beauty Valley Spa - Dermalogica Facial Form
Within the last year, have you had any health problems that have affected or could affect your skin?
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Yes
No
If "yes", please specify:
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List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly.
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Do you wear contact lenses?
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Yes
No
Do you have metal implants, a pacemaker, or body piercings?
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Yes
No
Do you have metal implants, a pacemaker, or body piercings?
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Yes
No
Do you have any allergies?
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Yes
No
If yes, please specify:
Do you have any sinus problems?
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Yes
No
Have you ever experienced claustrophobia?
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Yes
No
Your Skin
What are your specific concerns/challenges with your skin?
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What skin products are you currently using? -Soap -Cleanser -Toner -Moisturizer -Masque -Exfoliant -Eye Products -Other If any, please list:
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Have you had any chemical peels, microdermabrasion, or any resurfacing treatments within the last three months?
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Yes
No
Have you been waxed within the last 72 hours?
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Yes
No
Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
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Yes
No
Are you currently using any products that contain the following ingredients? -Glycolic Acid -Lactic Acid -Hydroxy Acids (AHAs, BHAs) -Vitamin A derivatives (i.e., Retinol) -any exfoliating scrubs If so, please list:
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Please specify if any of the following apply to you: -Pregnant -Trying to become pregnant -Lactating -Menstruating -Pre-menstrual If so, please list:
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By typing my name below, I confirm (to the best of my knowledge) that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment, and I consent to this service. This acts as my electronic signature.
1. Name:
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2. Phone number:
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3. Email:
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Submit
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