CONSULTATION FORM Client Name * First Name Last Name Email * Phone * (###) ### #### 1) What is your skin type? * Dry Oily Combination Normal Sensitive Acne-prone 2) Select that may apply. * Use of Accutane within last 6 months Epilepsy Heart disease Blood pressure History of Seizures Cancer, tumor or metastasis Rosacea Use of Aspirin Taking Cortisone injection or any other kind of steroid injection(s) Herpes Atopic dermatitis/ Eczema Pregnant / Lactating None of the above 3) Do you have any food allergies? * Yes No 4) Do you have any skin allergies? * Yes No 5) Are you taking birth control pills? * Yes No 6) Are you taking any medication? * Yes No 7) What is the date of your LMP (Last Menstrual Period), if applicable? 8) Do you have hormonal imbalance? * Yes No 9) Do you use AHA/BHA, Retinol, Vitamin A derivative product or Hydroquinone? If yes, explain 10) Have you had any skin treatment (including laser) within last one month? * Yes No 11) Do you have any metal or pacemaker, metallic implants, electrical implants or battery-operated device in your body? * Yes No 12) Do you have diabetes? If yes, is it controlled through medicine? 13) Are you prone to cold sores? * Yes No 14) Did you have Botox, Collagen, or other dermal filler injections in the area to be treated within last 14 days? * Yes No Any other information that you would like to share? How did you hear about us? Google Search Referral Instagram Other I certify that the above information provided is true and complete to the best of my knowledge. * Yes No Date * MM DD YYYY Initials Thank you!