Appointment Treatment Consent Form

Full Name:

Phone Number:

Email:

Birthday:

Have you ever been diagnosed with any of the following skin disorders?
AcneRosaceaEczema/PsoriasisSkin CancersContact DermatitisNone

Other:

Have you used or are you currently using any of the following skincare products?
AccutaneRetinolGlycolic Acid/Salycilic AcidVitamin CNone

Are you pregnant?
YesNo

Do any of the following apply to you?
SmokeWear ContactsTanningBirthcontrol PillsNone

Other:

Do you get botox or injectables?
YesNo

When was the last time you exfoliated and what did you use?

On a scale of 1-10, how would you rate your skin?

Are you on any medications or supplements? Please write yes or no and if yes, please list.

Do you have menopausal or hormonal issues? Please write yes or no and if yes, explain.

Please describe your skin type:

What are your present skincare concerns?
Fine Lines/WrinklesDryness/FlakyOiliness/ShininessCongestionBreakouts/AcneAcne ScarringEnlarged PoresHyperpigmentation/Brown Spots/Sun DamageRednessSensitivityLack of Firmness/ToneNone

What are you expecting from todays treatment?

If there is anything else you would like us to know before your upcoming appointment, please let us know.