Facial Pre-Treatment Questionnaire

Please complete the form before your visit to help us tailor your treatment for a safe, relaxing experience.

Facial
Does your job require that you work outdoors?
Your Skin Care
Have you ever had a facial treatment before?
Have you ever had chemical peels, laser treatments or microdermabrasion?
In the last month?
Have you been waxed or had a laser hair reduction treatment in the past week?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?
Have you used any of these products in the last 3 months?
Have you ever used an acne medication?
Have you had Botox, Restylane, Collagen or any other injectable?
Do you have any allergies?
Do you exfoliate regularly?
Have you exfoliated in the past 24 hours?
Have you ever had an adverse reaction after using a skin care product—rash, irritation, peeling, sun sensitivity, breakout…?
Have you been exposed to the sun or used a tanning bed in the last 48 hours?
Health History

Please answer the below questions honestly and completely as these conditions are relevant to your skin health and may be contraindications for treatment.

Are you pregnant or trying to become pregnant?
Do you have any metal implants or wear a pacemaker?
Have you ever experienced claustrophobia?
Have you had any of these health conditions in the past or do you have presently?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.