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Tell Us Who You Are
First Name
Last Name
Email
Phone
Birthday
How did you hear about us?
Within the last year, have you had any health problems that have affected or could affect your skin?
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Required
Yes
No
If yes, please specify:
List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly.
Do you wear contact lenses?
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Required
Yes
No
Do you have metal implants, a pacemaker or body piercings?
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Required
Yes
No
Do you have any allergies?
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Required
Yes
No
If yes, please specify:
Do you have sinus problems?
*
Required
Yes
No
Have you ever experienced claustrophobia?
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Required
Yes
No
What are your specific concerns/challenges with your skin?
What skin care products are you currently using?
Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?
*
Required
Yes
No
Have you been waxed within the last 72 hours?
*
Required
Yes
No
Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
*
Required
Yes
No
Are you currently using any products that contain the following ingredients? Glycolic Acid C, Lactic Acid C, any exfoliating scrubs, Other Hydroxy Acids, Vitamin A derivatives (i.e., Retinol)
*
Required
Yes
No
Please specify if any of the following apply to you: Pregnant, Trying to Become Pregnant, Lactating, Menstruating, Pre-menstrual
This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (i) to quality assurance and quality control personnel, (i) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information. I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
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