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Patient Profile
First Name
Last Name
Birthday
Age
Gender
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Phone
Email
ABOUT YOU
What is your hereditary background?
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Eastern
African American
Other
Natural Eye Color
Natural Hair Color
Describe your skin (check all that apply)
Normal
Dry
T-Zone
Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Blackheads
Millia
Cysts
Breakouts
Acne Scarred
Large Pores
Small Pores
Rosacea
Eczema
Freckled
Sundamaged
Malasma
Hyperpigmentation
Hypopigmentation
Uneven
Blotchy
Matured
Wrinkled
Patchy Dryness
Sallow
Psoriasis
Dehydrated
Lacking Moisture
Asphyxiated
Telangiectasia
Broken Surface Capillaries
Do you consider your skin:
Sensitive
Resilient
Unsure
What are the changes you'd most like to see in your skin?
LIFESTYLE
Are you pregnant or lactating? Please consult with your OB. (Only the Oxygenating Trio, Detox Gel Deep Pore Treatment or Hydrate Therapeutic Oat Milk Mask are appropriate.
Yes
No
Do you wear contacts? Remove contacts if sensitive or having microdermabrasion.
Yes
No
Do you currently have a sunburned/windburned/red face?
Yes
No
Are you in the habit of going to the tanning booth? If within the past 14 days we must decline treatment. This practice should also be discontinued due to risk of skin cancer and aging.
Yes
No
Do you engage in vigorous aerobic activity or sports?
Yes
No
Do you smoke or use tabacco?
Yes
No
What kind of work do you do?
On average, how many hours per week do you spend outdoors?
MEDICAL TREATMENT HISTORY
Do you currently use depilatories or wax? Is so, discontinue use 5 days pre and post treatment
Yes
No
Have you had a chemical peel or any type of procedure with a medical device?
Yes
No
Within the last 14 days?
Yes
No
If yes, what type?
Do you have regular Collagen, Botox, or other dermal filler injections? (Peels should procede or follow peels by two days to prevent movement of the filler or stinging at the injection site).
Yes
No
Have you recently had laser resurfacing or facial surgery?
Yes
No
If yes, what type and when?
Are you taking any of the following medications?
Tretinoin
Retin-A
Differin
Renova
Tazorac
Evage
Epiduo
Ziana
If yes, strength and length of use? (High percentages of certain ingredients may increase sensitivity. Discontinue use 5 days before and after treatment. Consult your physician before discontinuing use of any medication.
Have you ever undergone Accutane (isotretinoin) therapy? (If you are currently undergoing Accutane treatment please consult your physician. If you are no longer undergoing Accutane treatment it okay to apply ONE layer of the following: Ultra Peel I, Sensi Peel, Advanced Treatment Booster, Oxygenating Trio, Hydrate Therapeutic Oat Milk Mask, or Revitalize Therapeutic Papaya Mask)
Yes
No
Do you develop cold sores/fever blisters?
Yes
No
If yes, last breakout?
Are you allergic or sensitive to any of the following?
Milk
Apple
Citrus
Grapes
Aloe Vera
Aspirin
Perfumes
Latex
Hydroquinine
Mushrooms
List any other allergies here:
Have you ever used any other products that have caused a bad reaction?
Yes
No
If yes, describe:
Your Signature
Clear
Submit
Thank you!
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