Skin Care Consultation Form

Name *

First

Last

Date *

Address *

Email *

What is your main goal for today’s treatment? *

Have you ever had an allergic reaction to any of the following?

If you have any other allergies, please list them here:

Are you currently taking any medications? *

If yes, please list them here:

Have you ever had any of the following conditions?

Rate your stress level (5 being the highest) *

Do you exercise? *

What areas of concern do you have regarding your skin:

If you selected other, please specify here:

Have you ever had a facial before? *

If yes, when?

Do you use Retin-A, Renova, AHA or Retinol derivative products? *

If yes, please specify what you use:

If yes, please specify how long ago you started using:

Have you ever had chemical peels, laser or microdermabrasion? *

If yes, when?

Have you ever used an acne medicine? *

If yes, when?

If yes, which drug?

What skin care products are you currently using?

If other, please specify:

Please list brands for skin care products you use, if known:

Is there any other information your skin care specialist should know?

Please enter your name to sign this form *

Birthday *

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