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About
Client Reviews
Services
Procell Microchanneling
Client Forms
Book
Portfolio
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Preferred Pronoun
Email
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
(###)
###
####
Occupation
*
How did you hear about me?
*
Current Skin Care & Lifestyle
Client’s Skin Type
*
Fair- always burns, never tans
Light skin tones- can burn, sometimes tans
Medium to olive skin tones, tans easily
Light brown to medium brown skin tones
Brown, moderately pigmented skin
Dark brown/black skin tones
Client's Skin Condition
I have desert skin. It's so dry!
I'm not dewy, I'm oily and it's too much.
I am a little bit dry and a little bit oily in some spots.
I have some bumps every so often
I have lots of bumps, help me!
Unsure
How do you currently wash your face?
*
If soap, what brand?
*
If cleanser, what brand?
*
Do you use moisturizer?
*
Yes
No
Are you on a special diet?
*
Yes
No
If yes, please specify:
Daily water consumption:
*
Daily coffee, tea, or soda consumption:
*
Amount of exercise per week:
*
Have you ever had a facial?
*
Yes
No
If yes when was your last facial?
Do you give yourself facials at home?
*
Yes
No
If yes how often?
List any additional cosmetics and skincare products you are currently using:
*
What is the primary reason for your visit today?
*
Medical History
Are you currently under the care of a physician for any reason?
*
Yes
No
If yes, what for?
For the following, please check any that are applicable to you.
*
Medications, supplements, or vitamins
Seasonal Allergies
Accutane
Antibiotics
Birth Control
Hormones
Aspirin, ibuprofen usage
Retin-A, Tretinoin
Metrogel, MetroCream
Glycolic Acid
Antidepressants
Sun Reaction
Medication Allergies
Food Allergies
Aspirin Allergy
Latex Allergy
Lidocaine Allergy
Hydrocortisone Allergy
Hydroquinone Allergy
Diabetes
Smoking History
Cold Sores, Herpes
Bleeding Disorder
AutoImmune Disorder, HIV
Pregnant/ planning to be
Nursing
Pacemaker
Implants of any kind
Migraine Headaches
Glaucoma
Cancer
Arthritis
Hepatitis
Thyroid Imbalance
Seizure Disorder
Active Infection
Skin Radiation in last 3 months
Acne
Melasma
Tattoos, Perm makeup, microblading
Vitiligo
Keloid Scarring
Skin/Laser Treatments
Botox
Fillers
Hair Removal
Chemical Peels
Sun Exposure/tanning bed or self tanner
None of the Above
List Medical Issues Not Listed Above or Any Dietary Allergies
*
I certify that the proceeding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical and health conditions and to update this information at subsequent visits. A current history is essential for the provider to execute appropriate treatment procedures. I have signed the consent form for this procedure. I had the opportunity to ask questions prior to the treatment. I accept arbitration as a means of resolution for practice liability.
Thank you!