First and last name*

Mobile number*

Email address

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.*

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

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.*

Are you lactating? (female clients only)

Any menopause problems? (female clients only)

Are you pregnant or trying to become pregnant? (female clients only)

Have you ever had an allergic reaction to product ingredients, fragrance, medications, foods, latex, etc?*

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

List your daily consumption of: Water*

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

Have you used an acne medication?*

If yes, when and which drug?

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

What is your stress level?*

Do you smoke?*

Any skin cancer?*

Any recent surgery, including plastic surgery?*

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*

Emergency Contact:*

Emergency Contact's Phone number:*