Skincare Form/WaiverPlease fill these out before your visit to save time and get right to your appointment Name * First Name Last Name Phone Number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Age * Referred by Occupation * What is your current stress level? * High Medium Low If you have been treated for any of the following please check the box * Acne Depression Skin Disease High Blood Pressure Cold Sores Diabetes Cancer Epilepsy Pacemaker/ Defibrillator/ ICD None Are you pregnant? * Yes No Are you on hormone therapy? * Yes No Are you prone to cold sores? * Yes No Do you smoke? * Yes No Do you have allergies to nickle, gold, copper, or tin metals? If yes, please tell us which one below. Please list all allergies: * Please list all medications: * please include any prescription skincare from your dermatologist here. Are you on prescription skincare from a dermatologist? * Yes No Do you take supplements? * Yes No Approx. how many ounces of water do you drink a day? * Have you ever had skin cancer? * Yes No Do you use sunblock on your face daily? * Yes No Sometimes How long ago was your last sunburn? * Do you use tanning beds? * Yes No Do you get professional facials? * Yes No If yes, how long ago was your last facial session? What skincare line(s) are you currently using on your skin? * How do you feel about the overall quality of your skin? * Very Happy Good Unhappy Your skin type is: * Normal Dry Dehydrated Oily Acne Acne Prone Rosacea For massage during treatment what pressure do you prefer? * Light Medium Deep Thank you!
