The following information is needed to ensure your well_being during a treatment or consultation for a custom regimen. It is important for me to know of any conditions that may cause a reaction from a treatment. All information will be kept confidential. Each condition will influence how I perform a treatment or decide to recommend a product. Please provide me with extended information if necessary
| Gender|| NOTE IF UNDER 18 – MUST HAVE PARENTAL CONSENT SEE SIGNATURES|
|Questions about lifestyle|
| Do you Smoke?|| |
| Do you burn easily in the sun?|| |
| Do you swim in a chlorinated pool on a regular basis?|| |
| Do you use fabric softener or sheets in the dryer?|| |
| Have you been diagnosed with rosacea or acne rosacea?|| |
| Are you using any hormonal birth control pills, shots, or IUD|| |
| What Kind? |
|Do you blush easily?|
| How Sensitive is your skin on a scale of 1 to 10? |
|Occupation Specify Here || |
Skip if Not Applicable
What Medications or Over the Counter Products Have You Tried in the Past For Acne, Discoloration,
and/or other issues?
|Other Oral Vitamins , Medications, or other Topical Prescriptions For Acne, Rosacea, Discoloration, or Anti_Aging? Specify Here:|
Please send me close-up pictures of all the areas of concern…the closer the better and one
full face at a distance. Text to me at 408_509_5092 or email at email@example.com
Please confirm the answers:
I have given are correct, and I have not withheld any relevant information. I understand that withholding or providing misinformation may result in a contraindications and/or irritation to my skin. The treatments I receive here are voluntary and recommended or purchased products are used at my own risk. I understand that by signing this waiver, I waive and release any rights to pursue damages against MeMe Glick, Beautify Your Skin Inc, and their employees or affiliates should any side effects occur.
Please Type your name below to consent that you understand these terms.