Name * First Name Last Name Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday Subject * Message * Medical: Are you currently or have you been under the care of a doctor within the last year? Explain: Health Problems: Diabetes, Thyroid, Heart, Cancer, Hysterectomy. Hormone Imbalance, Epilepsy, Diet, Other? Medications, Drugs, & Vitamins (List all and reason for taking)? Do you take any of the following? Retin-A Accutane , Diet Tablets, Cigarettes, Diuretics, Stimulants, Oral Contraceptives, Laxatives, Other? Have you undergone any surgery recently? When was your last visit to the dermatologist? Do you use injectables (Botox, etc.)? Have you had any X-rays recently? Do you have any metal implants? How many hours do you work? Do you sleep & exercise regularly? What is your daily consumption (in ounces) of each of the following: water, coffee, tea, soft drinks, or other? What water temperature do you cleanse with? What is your current skin condition? Dry, Oily, Combination, Not sure? Any special skin problems (Flaking, tightness, other)? Have you had a reaction to any treatments? Do you experience any skin breakouts? Does PABA effect you in any way? Current skin care routine (Soap, cleanser, toner, scrub, moisturizer, masque, other, share details): Do you blush easily, sunburn, and/or have a redness tendency? Massage preference; firm or light? What is your pain threshold? Low, medium, or high? Do you have any sinus problems? Explain: Do you have reactions to cosmetics, metals, pollen, food, or animals? Explain: Female clients only. Are you pregnant or trying to be? Are you due for your menstrual period in the next week? Who referred you? Thank you! Please fill out the form below:
