Date *

MM

DD

YYYY

Name *

First Name

Last Name

Skin Type: *

Normal

Oily

Combination

Dry

Sensitive

Mature

How would you rate your skin? *

Always Burns, Never Tans

Burns Easily, Tans Slightly

Burns Moderately, Tans Gradually

Seldom Burns, Always Tans Well

Rarely Burns, Deep Tan

Never Burns, Deeply Pigmented

What special areas of concern do you have? *

Acne Scarring

Fine Lines & Wrinkles

Pigmentation

Sun Damage

Age Spots

Acne

Do you? *

Sunbathe

Use a Tanning Bed

Never

Have you ever used:

Accutane

Retin-A

Renova

Topical Antibiotic

Hydroquinone

Have you ever had a reaction to:

Metals

Fragrance

Medication

Airborne Particles

Food

Cosmetics

Other Allergies (Milk, Apples, Citrus, Grapes, Aloe Vera, Aspirin)

How would you describe your overall health? *

Excellent

Good

Fair

Poor

Have you had any of the following?

Acne

Allergies

Arthritis or Bursitis

Irregular Blood Pressure

Breast Implants

Cataracts

High Cholesterol

Claustrophobia

Diabetes

Diarrhea/Constipation

Eczema

Epilepsy

Hay Fever

Headaches

Heart Problems

Hepatitis

Hirsutism

HIV

Hormone Imbalance

Infections

Lupus

Metal Implants

Pace Maker

Phlebitis

Psoriasis or Vitiligo

Serious Injury

Thyroid

Varicose Veins

How much water do you drink a day? *

Less than 8 glasses

8 glasses a day

More than 8 glasses

How many cups of caffeine do you consume daily?

Coffee, Tea, Soft Drinks

None

1-3 Cups

4 or more

What is your stress level? *

Low

Medium

High

Informed Release *

I fully understand all the questions above and have answered them correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the practitioner will completely inform me of what to expect in the course of treatment, and will recommend adjustments to my regimen if deemed necessary. I have completely discussed my concerns and have had my questions answered. I also am aware that individual results are dependent upon my age, health condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my practitioner immediately. I release the therapist, and the staff harmless from any liability that may result from this treatment.

First Name

Last Name

Date *

MM

DD

YYYY