First and last name*

Mobile number*

Email address*

Address*

Apartment, suite or unit number

City*

Date:*

Any skin cancer?*

If yes, please explain further:

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 form thick or raised scars from cuts or burns?*

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

If yes, describe further:

Do you wear contact lenses?*

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

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

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

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

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

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

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

Have you ever had an allergic reaction to Cosmetics*

Have you ever had an allergic reaction to Medicine*

Have you ever had an allergic reaction to Food*

Have you ever had an allergic reaction to Animals*

Have you ever had an allergic reaction to Sunscreens*

Have you ever had an allergic reaction to AHAs*

Have you ever had an allergic reaction to Fragrance*

Have you ever had an allergic reaction to Latex*

Have you ever had an allergic reaction to Drugs*

If other, please specify:

If yes, explain further:

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.*