Your visit to our skin care clinic is the beginning of a positive relationship between you and the esthetician. Good skin care products and professional skin care regimens are important in maintaining healthy skin. Clinical skin care treatments provide 50% of skin improvements and the remaining 50% is done with the prescribed home care products. Please feel free to inform your aesthetics technician of any changes in between each visit.

Tell us about you! Please complete the following informational form prior to your first appointment.

Today's date *
Today's date
Name *
Phone *
Home care products (check all that apply): *
Please check any of the following conditions you have or may have had in the past: *
Identify your stress level *
In the past three months have you used any of the following types of products? *
Are you pregnant, trying to get pregnant, or lactating? *
Are you menopausal, in menopause or post-menopausal? *
Have you been exposed to the sun or used a tanning bed in the past 24 hours? *
Do you wear contact lenses or glasses? *
Have you ever had an adverse reaction after using any skin care product? *
Have you had skin care treatments in the past? *
It may be necessary to change your current regimen for optimum results. Is this okay? *
Do you usually break out after skin care treatments? *
Have you experienced unexplained itching, swelling, flaking or redness after a facial? *
Do you use sun block daily? *
Do you suffer from hyper or hypopigmentation? *
Are you experiencing any of the following skin care problems? (check all that apply) *