Name:*

Address:*

City:*

State*

Zip:*

Home/Cell phone:*

Work Phone:*

Email Address:*

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*

Are you using any other skin thinning products and/or drugs?*

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

Do you use a tanning bed?*

Are you diabetic?*

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):

What skin products do you regularly use on your skin?

Have you ever been treated for cancer? If yes, when and what types of therapies were used?

Please list any other illness/condition you are currently being treated for by a medical professional

(Female clients) When is your next menstrual cycle due to begin?

Age