Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What are your skin goals and concerns?
*
What is your skin type?
*
Dry
Oily
Normal/combination
Acne
Mature
Sensitive
What skincare/makeup products are you currently using? Have you have any reactions to them? Explain.
*
Do you wax your skin on a regular basis. If so, when was the last time?
*
Have you have any facials, chemical peel, microdermabrasion or any resurfacing treatments in the last 4-6 weeks?
*
Yes
No
Are you using Retin-A?
*
Yes
No
Are you using Benzoyl Peroxide?
*
Yes
No
Are you taking any of the following medications? Check all that apply.
*
Accutane
Birth control
Antibiotics
None
Other
Do you have any of the following heath issues? Check all that apply.
*
Cancer
Circulation issues
Arthritis
Hormonal imbalances
Diabetes
Pregnant
Lactating
Psoriasis
Cold sores
Chemotherapy
High blood pressure
Hysterectomy
Thyroid
Eczema
Recent surgeries
None
Other
Have you ever experienced a reaction to any of the following?
*
Cosmetics
Medicine
Iodine(shellfish)
Latex
Pollen
Frangrance
Alpha hydroxy acids
Sunscreens
None
Other
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release Laci Aesthetics from any liability.
*
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