First and last name*

Mobile number*

Email address

Address

Apartment, suite or unit number

City

Date:*

Cell Phone:*

Emergency Contact:*

Emergency Contact's Phone number:*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*

If yes, describe:

Have you used any of these products in the last 3 months?*

Have you used an acne medication?*

If yes, when and which drug?

Do you have any metal implants or wear a pacemaker?*

Have you ever had irritation after using any skin care product?*

Have you ever had an allergic reaction to AHAs (Glycolic, Mandelic, Lactic Acids)*

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.*

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.*

I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history.*

I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.*