Pine and Pearl Esthetics

Any skin cancer?* required

Yes

No

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

Yes

No

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

Yes

No

Have you used an acne medication?* required

Yes

No

Do you form thick or raised scars from cuts or burns?* required

Yes

No

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

Yes

No

Do you wear contact lenses?* required

Yes

No

Have you been exposed to the sun or used a tanning bed in the last 48 hours?* required

Yes

No

How frequently are you exposed to the sun or use a tanning bed?

Infrequently

Frequently

Regularly

Have you ever had a rash after using any skin care product?* required

Yes

No

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

Yes

No

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

Yes

No

Have you ever had sun sensitivity after using any skin care product?* required

Yes

No

Have you ever had a breakout after using any skin care product?* required

Yes

No

Have you ever had an allergic reaction to Cosmetics* required

Yes

No

Have you ever had an allergic reaction to Medicine* required

Yes

No

Have you ever had an allergic reaction to Food* required

Yes

No

Have you ever had an allergic reaction to Animals* required

Yes

No

Have you ever had an allergic reaction to Sunscreens* required

Yes

No

Have you ever had an allergic reaction to AHAs* required

Yes

No

Have you ever had an allergic reaction to Fragrance* required

Yes

No

Have you ever had an allergic reaction to Latex* required

Yes

No

Have you ever had an allergic reaction to Drugs* required

Yes

No

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.* required

Yes

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

Yes

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.* required

Yes

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.* required

Yes