Skin Care Consult

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Have you ever had a facial treatment before?

If yes, when?

Which of the following best describes your skin type?

List any specific skin problems or concerns pertaining to your face/body.

Have you ever had chemical peels, laser, or Microdermabrasion?

Have you had any of these services within the last month?

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A derivative products?

Have you used any of these products within the last 3 months?

Please last any acne medications you have used and the dates from which they were used.

Please list all skin care products you are currently using as well as the brand.

Have you recently used any self-tanning lotions, creams, or treatments?

What areas of concern do you have regarding your skin?

Please list any known allergies.

What SPF do you use on your face? How often/when?

What SPF do you use on your body? How often/when?

Have you experienced Botox, Restylane, or Collagen injections?

Male Clients Only

What is your current shaving system?

Do you experience irritation from shaving?

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. The treatments I receive here are voluntary and I release this institution Angela Tommasi from liability and assume full responsibility thereof.

Please list any additional comments and/or concerns.

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