New Facial/Peel Client Paperwork

Name *

DOB *

Month

Day

Year

Address *

City/State/Zip *

Phone # *

E-mail *

Emergency Contact *

Dermatologist/Physician *

Dermatologist/Physician Phone

Occupation *

Referred by

Are you presently under a physician's care for any current skin conditions or other problems? *

Are you taking oral medications and/or supplements? *

What kind?

Have you ever used products that caused a bad reaction? *

What kind?

Do you have any allergies to cosmetics, foods, or drugs? *

Describe the reaction.

Do you have any new Botox or fillers? *

Approximately how long ago?

Have you had skin cancer? *

Do you wear contact lenses? *

Do you smoke? *

How much water do you consume daily? *

Do you suffer from sinus problems? *

How would you rate your skin? *

Always Burn

Burns Easily, tans slightly

Burns moderately, tans gradually

Seldom burns, always tans well

Rarely burns, deep tan

Never burns, deeply pigmented

Do you use tanning beds? *

Have you ever had microdermabrasion? *

Have you had chemical peels? *

Have you had any resurfacing treatments? *

Are you currently using any depilatories or facial waxing? *

Are you prone to cold sores? *

Do you have medication you take to treat them, and if so, what is it?

Have you ever taken Accutane? *

How long ago?

Are you currently using any prescription topical medications or exfoliating products? *

Does your skin feel tight and dry after cleansing? *

Do you get oily during the day? *

Do you ever experience breakouts? *

Briefly explain.

What other skin care products are you currently using?