Skin Issues and Concerns

1
Date of Application
Date
Month
Day
Year
2
Full Name
First Name
Last Name
3
Date of Birth
Month
Day
Year
4
Are you currently under the care of a physician?
Yes
No
5
Have you experienced any of the following health conditions in the past or present?
Hormone Imbalance
Cancer/Systemic Diseases
High Blood Pressure
Diabetes
Heart Problems
Arthritis
Auto-Immune Disorder
Asthma
Epilepsy/Seizures
Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Headaches/Migraines
None
Other
6
Other (please specify)
7
Any known allergies
Aspirin
Latex
Fruits
Shellfish
Lidocaine
Fragrance/Essential Oils
Nuts
Dairy
Sunscreen
Pollen
None
Other
8
Other (please specify)
9
Have you ever received any botox or fillers?
Yes
No
10
If yes, when and where? (comments)
11
If yes, when did you receive botox or fillers?
Date
Month
Day
Year
12
If yes, where did you receive botox or fillers?
13
What would you say your skin type is?* This field is required.
Normal (no visible blemishes, fine pores, smooth texture)
Sensitive (reactive to fragrance, often irritated)
Combination (oily and dry patches, oily t-zone, hormonal breakouts)
Oily (enlarged pores, excessive oil)
Acne (cystic or nodules)
Dry (dull, visible lines and wrinkles, feels tight)
14
What are your current skin care goals/concerns?
15
Do you currently use roaccutane or any antibiotics for your skin?
16
Do you experience any breakouts or acne?* This field is required.
Yes
No
17
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last month
Yes, within the last 2-3 months
No
18
Have you been diagnosed with eczema, psoriasis or rosacea?
Yes
No
19
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Smoke
Frequent tanning beds
20
Are you taking birth control?
Yes
No
21
Are you pregnant or breastfeeding?
Yes
No
22
Consent StatementI acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly no medical claims have been expressed or implied. I acknowledge that I should avoid use of Retin-A type products, aggressive exfoliation, waxing and products containing acids that are no part of the recommended take-home regiemen for 2-4 weeks following treatment. I consent (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 give consent for all future treatments. I release Verity Aesthetics of any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.
23
I agree to the above consent* This field is required.
Yes
No
24
Signature
25
Please attach 3 photos of your skin
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26
How would you like us to contact you?* This field is required.
WhatsApp
Instagram
Email
27
Instagram name
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