Name
*
First Name
Last Name
Email
*
What treatments are you wanting to have done?
*
Have you had any health problems that have affected or could affect your skin within the last year?
*
Yes
No
Are you prone to keloid scarring, blisters, or cold sores?
*
Yes
No
List any medications, supplements, vitamins, diuretics, oral contreceptives, Isotretinoid, ect. that you take regularly.
Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments?
*
Yes
No
Do you wear contact lenses?
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Yes
No
Do you have any metal implants, a pacemaker, or body piercings?
*
Yes
No
Do you have any allergies?
*
Yes
No
If YES, please specify
List allergies and products you are allergic to.
Do you have any sinus problems?
*
Yes
No
Have you ever experienced clostrophobia?
*
Yes
No
What are some specific concerns / challenges with your skin?
What skin care products are you currently using?
*
Have you had chemical peels, microdermabrasion, or any resurfacing treatments within the last 2 weeks?
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Yes
No
Have you had any facial waxing within the last 2 weeks?
*
Yes
No
Have you used retinol, tretinoin, or other prescription skin products withing the last 3 months?
*
Yes
No
Please check all ingredients you are currently using with your skin care.
Have you received a cosmetic light-based procedure such as laser treatment, IPL, ect. within the last 6 weeks?
*
Yes
No
Do you have active cold sores?
*
Yes
No
Have you ever received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the last 4 week?
*
Yes
No
Do you sunbathe or use tanning beds?
*
Yes
No
Do you experience redness, itching, or stinging on you skin?
*
Yes
No
I understand that results will vary between individuals. I understand that although I may see change after my first treatment, I may require a series of sessions to obtain my desired results. I am aware that though good results are expected, the possibility and nature of complications cannot be full anticipated. Therfore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the results of this treatment are not permanent as natural degradation will occur over time. I confirm that the information I have provided on the form is accurate. to the best of my knowledge. and that I have not withheld any information that will be relevant to my treatment.
