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What is your main skin care goal?
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What products are you currently using at home currently?
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Are you currently pregnant or lactating?
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Yes
No
Might be
Are you currently undergoing cancer treatments?
*
Yes
No
If yes, please provide any additional information on your current treatment plan. This information is helpful in creating a skincare treatment plan while undergoing your cancer treatment.
Are you current under physician care for any skin related issues?
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Yes
No
If yes, what are you being treated for?
Are you currently on any prescription medications orally or topically?
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Yes
No
If yes, please list all medications.
Have you had any of these health conditions in the past or present?
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None
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart problem
Varicose veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure disorder
Fever blisters
Headaches
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Blood clotting abnormalities
Psychological treatment
Insomnia
Keloid scarring
Skin disease/skin lesions
Any active infection
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
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Yes, currently using
Yes, but not within last 30 days
Yes, but not within 6 month
No
Do you have any heart related issues. I.E. PACEMAKER, GOLD THREADS, HEART VALVE REPLACEMENT
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Yes
No
Have you ever experienced claustrophobia?
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Yes
No
Have you had any Botox, Fillers or Injectables in the past 30 days?
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Yes
No
Are you allergic to?
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No Known Allergies
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Fragrances/Essential Oils
Shellfish
Iodine
Other
If you checked yes to any of these, please list your allergy.
Post Facial Care Instructions: Aerobic exercise or vigorous physical activity should be avoided for the first 48 hours. Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with a SPF of 30 or greater. Sunscreen (with at least a SPF of 15) should become a part of your daily skin care regimen as your skin will become more sensitive to the sun as a result of this treatment. Cleanse your face with water and a mild cleanser. Use a gentle moisturizer and SPF. DO NOT apply any type of glycolic acid or exfoliation products as this can severely damage or irritate the skin during the entire healing process.If your having a Microderm, Any Epidermal Abrasion Treatment )Epidermal Leveling, Derma Disc Derma File or Enzyme or Chemical peel, you may experience flushing of the skin. slight flakiness and sensitivity for up o 48-72 hours post treatment.DO NOT peel, rub, or scratch your skin at anytime, whatsoever. This WILL cause damage and compromise your results as well as possibly cause severe scarring.
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I understand the post care instructions and agree to adhere to them.
RESERVATION and CANCELLATION POLICY for All current and Future Appointments:: CREDIT CARD IS REQUIRED FOR ALL APPOINTMENT INCLUDING VOUCHER, GIFT CERTIFICATES AND PREPAID SERVICE. 48 hours ADVANCE NOTICE OF CANCELLATION REQUIRED. LESS THAN A 48 hours NOTICE WILL INCUR A $39 FEE. NO SHOWS WILL BE CHARGED 100%*
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I UNDERSTAND THE RESERVATION AND CANCELLATION POLICIES AT ALLURE SKINCARE STUDIO AND CONSENT TO MY CREDIT CARD ON FILE BEING CHARGED IF i FAIL TO GIVE 48 hours NOTICE OF CANCELLATION OR NO SHOW ANY OF MY CURRENT AND FUTURE APPOINTMENT.
ALLURE SKINCARE STUDIO ONLY ALLOWS THE USE OF 1 (ONE) GROUPON PER CLIENT. GROUPONS ARE FOR NEW CLIENTS ONLY OR THOSE NOT ACTIVE FOR 6 MONTHS. GRATUITY IS NOT INCLUDED.
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I am aware of the Groupon PolIcies
Signature
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