• Skin Health Assessment

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Your Skin Vision

  • What are your skin care concerns?*
  • Have you ever had a facial or skin treatment before?
  • Current skin care rountine*

  •  If applicable, please list your current products (BRAND & PRODUCT TYPE/NAME) 

  • Including retinoids, Accutane, Differin, AHA, BHAs, vitamin A derivative
  • Have you received any of these hair removal services in the last 14 days?*
  • Have you had professional skin treatments recently? (including chemical peels, laser resurfacing, microdermabrasion)
  • Have you received any injectable’s in the last two weeks?

  • Your Health

  • Please disclose any relevant medical history?*
  • Do you have any of the following??*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?
  • Are you a smoker?
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
  • Have you ever experienced claustrophobia?
  • Please rate your stress level

  • FEMALE CLIENTS

  • Are you taking birth control?
  • Are you pregnant or trying to become pregnant?
  • Any menopause issues?
  • Are you undergoing any hormone replacement therapy?

  • MALE CLIENTS

  • What is your current shaving system?
  • Do you experience irritation from shaving?
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  • Date*
     - -
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