Client Name:

 
Address:

 
Phone Number:

 
Are you currently taking any medications such as Retin- A, Differin, Tazorac or Accutane?

 
Are you taking or topically applying any other medications at this time?

 
Any known allergies:

 
Are you pregnant, trying to get pregnant or nursing?

 
Do you sunbathe or use tanning beds?

 
Do you experience cold sores? If so, last break out?

 
Describe your home skin care regime:

 
What improvements would you like to see with your skin?

 
List any other information that we should know that would be relevant to your treatment:

 
I confirm that prior to receiving my treatment, that I have been candid in revealing any condition that may have a bearing on this treatment. I understand that there may be some degree of discomfort and there are no guarantees as to the results of this treatment, due to many variables such as condition of skin, sun damage, smoking, climate,age, etc.

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