Date:

Full Legal Name (Digital Signature):

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 the company and/or skin care professional from liability. By typing my full legal name below, I also acknowledge agreement with all studio, cancellation, and late policies.

Birth Control?

Antibiotics?

Accutane?

Do you take any medications?

Eczema

Recent Surgeries

Planning to be pregnant

Pregnant

Thyroid

Hysterectomy

High Blood Pressure

Chemo-therapy

Cold Sores

Psoriasis

Lactating

Diabetes

Hormonal Imbalance

Arthritis

Circulatory Issues

Cancer

Do you have any of the below health issues?
(Please type an "X" next to all that apply)

Sunscreens

Alpha Hydroxy Acids

Fragrance

Animals

Food/Fruit

Pollen

Latex

Iodine (shellfish)

Medicine

Cosmetics

Have you ever experienced a reaction to any of the following?
(Please type an "X" next to all that apply)

Do you have any allergies or sensitivities?

 Are you using Benzoyl Peroxide?

Are you using Retin-A?

Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments? If yes, was it within the last month?

Do you wax your facial skin on a regular basis? If yes, when was the last time?

Does your job and lifestyle require that you work/play outdoors?

What makeup products are you currently using?

What skin products are you currently using?

Mature & Aging

Moderate Acne

Mild Acne

Dry

Sensitive

Oily

Normal/Combo

Your Skin Type:
(Please type an "X" next to all that apply)

Your Skin Goals and Concerns:

Phone:

Emergency Contact:

Email:

Phone:

Address:

Date of Birth:

Name: