Consent to Treat Have Questions? Please complete this questionnaire below prior to your first appointment.Privacy Policy | Terms of Use Name * First Name Last Name Phone * (###) ### #### Email * Please list any allergies you have: * Please include both food and environmental allergies. Have you ever had a facial treatment? * Yes No If yes, which treatment(s) have you had and when? Have you have had any reactions or sensitivities facial products or treatments? * Yes No If yes, please explain. Do you use any form of retinol/vitamin A-derivative products, Epiduo, Accutane or any other prescriptions from a dermatologist? * Yes No If yes, please list them. Have you had any injuries or procedures that might affect your facial treatments? * Have you recently had Botox, Restylane or any other injections? * Yes No What is your method of hair removal? * What would you like to achieve from your treatment today? * How many glasses of water do you drink a day? * How many alcoholic beverages do you drink in a week? * How many hours of sleep do you get per night? * Which of the following foods do you eat on a regular basis? * Select all that apply. Dairy Eggs Grain/Bread Fish Fruit Poultry Processed Sugars Red Meat Vegetables How many times a week do you exercise? * What is your current stress level on a scale of 1 to 5, 5 being the highest. * Existing Medical Conditions * Select any and all of the following conditions that apply to you. None Acne AIDS Auto-Immune Disease Cancer Claustrophobic Cold Sore(s) Diabetes Eczema Epilepsy Hepatitis High Blood Pressure Keloid(s) Pacemaker Pregnant Psoriasis Rosacea Smoker Tooth Fillings and/or Crowns Wear Contacts If pregnant, how many months are you? Please list any other medical conditions I should be aware of. I have completed the above questionnaire fully and truthfully. 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 and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof. * I agree to the above statement and consent to treat. Today's Date * MM DD YYYY Thank you!
