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Consultation Form

This consultation form is designed to gather essential information about your skin, lifestyle, and preferences to ensure we offer you the best possible guidance and products.
Within the last year, have you been under a dermatologist's or other physican's care?
Within the last nine months, have you undergone any surgery?
Have you had any health problems in the past or present?

Your Health

Are you prone to cold sores?
Do you smoke?
Do you wear contact lenses?
Do you have metal implants, a pacemaker, or body piercings?
Rate your level of stress on a scale of 1 to 4 (1 = low stress; 4 = high stress):

Exfoliation History

Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?
If YES, were they in a medical setting?
Do you use Accutane, Retin A, Renova, Adapalene (Differin), Hydroquinone, Tazorac, or any other prescription skin products?

Moisture Hydration

Do you ever experience these conditions on your skin?

Capillary Activity

Do you have a tendency to redness?

Oil Secretion

Do you have a family history of skin breakouts?
Do you have consistent skin breakouts?
Has it been longer than 3 years since your last skin breakout?

Nerve Activity

Do you drink more than 4 caffeinated beverages daily? (Coffee, tea, soft drinks)
Do you ever experience a burning, itching sensation on your skin?
What is your pain threshold?
Have you ever experienced claustrophobia?
What type of massage pressure do you prefer?
Have you ever had a reaction to any of the following?

Questions to discuss at every visit

Are you using any hormone-based treatment (birth control, HRT, etc.)?
Are you taking oral contraception?
Are you pregnant or trying to become pregnant?
Are you lactating?
Are you currently having or due for your menstual period?
Have you started any new medications(s) since your last visit?

Guest Information

The Skin Consultation Card is used to properly evaluate your special skin care needs. This information is confidential and may be disclosed only to staff members or risk or quality improvement personnel to assess the quality of care and will not be passed on to a third party.

Thank you for filling out the form, We will see you at your appointment!

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