Consent Form
Within the last year, have you been under a dermatologist's or other physician's care?
Do you wear contact lenses?
Have you had any health problems in the past or present?
Do you have metal implants, a pacemaker or body piercings?
Have you ever experienced claustrophobia?
Have you had a chemical peel, microdermabrasion, laser or light therapy, an injectable, or other cosmetic procedure in the last month?
Have you waxed within the last 72 hours?
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products?
Do you have any allergies?
What skin care products are you using?
Are you pregnant or trying to become pregnant?
Are you currently using any products that contain the following ingredients?
List any medications, supplements, vitamins, etc. that you take
regularly:
Have you taken isotretinoin (accutane) within the last 6 - 12 months?
What are your specific concerns or challenges with your skin?
Your Health
Your Skin
face:
body:
Female Clients
Are you breastfeeding?
Are you prone to cold sores or fever blisters?
Glycolic acid
Lactic acid
Any exfoliating scrubs
Any hydroxy acid product
Vitamin A derivatives (i.e. Retinol)
Soap
Shower Gel
Scrubs
Oil
Body Moisturizer
Depilatory
Self Tanners
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
Serums