Facial Consultation Form

Name *

First Name

Last Name

Within the last year, have you had any health problems that have affected or could affect your skin? *

Yes

No

Do you wear contact lenses? *

Yes

No

Do you have metal implants, a pacemaker or body piercings? *

Yes

No

Do you have any allergies? *

Yes

No

Do you have sinus problems? *

Yes

No

Have you ever experienced claustrophobia? *

Yes

No

What skin care products are you currently using? *

Soap

Masque

Cleanser

Exfoliant

Toner

Eye Products

Moisturiser

Other

Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months? *

Yes

No

Have you been waxed within the last 72 hours? *

Yes

No

Have you shaved within the last 24 hours *

Yes

No

Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months? *

Yes

No

Are you currently using any products that contain the following ingredients? *

Glycolic Acid

Lactic Acid

Other Hydroxy Acids

Vitamin A derivatives (i.e., Retinol)

any exfoliating scrubs

Please specify if any of the following apply to you: *

Pregnant

trying to become pregnant

lactating

menstruating

pre menstrual

Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? *

Yes

No

Do you have active cold sores? *

Yes

No

Have you received Botox or other injectable procedures within the past week? *

Yes

No

Do you sunbathe or use tanning beds? *

Yes

No

Do you experience redness, itching, or stinging on your skin? *

Yes

No