Consultation Form [raw] Step 1 of 4 - Contact Information 25% Today's Date MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Gender Female Male Phone*Email* Emergency Contact Emergency Contact Phone Ethnic Skin Type* Caucasian African-American Hispanic Asian Eastern Indian American Indian How much UV exposure do you get?*-- Please Select --1-2 hours per day3-4 hours per day5-6 hours per day7+ hours per daySun, Tanning Bed, Commuting in Car etc.Which applies to you? Always Burn Tan with Difficulty, Usually Burn Average Tanning, Sometimes Burn Easily Tan, Rarely Burn Never Burn Do you suffer from... Acne Blackheads Whiteheads Oiliness Rosacea Dehydration Eczema Vein/Circulation Problems Psoriasis Other Select all that applyPlease List "Other" Affected Body Location(s)Do you have any of the following? Scars Stretch Marks Hyper Pigmentation What is your typical Stress Level?*1 (low)2345678910 (high)How often do you excercise?NeverSometimesFrequentlyHow much sleep do you get each night?hoursHow many ounces of water do you drink daily?How much caffeine and/or alcohol do you consume each day?Do you smoke? Yes No Please list any health conditions you are currently experiencingHave you taken any of the listed medications in the last 6 weeks? Retin A Accutane Topical Antibiotics Oral Antibiotics Blood Thinners/Blood Pressure Medication Have you had any Chemotherapy treatments in the last 6 months? Yes No What is the name of the Antibiotic? Please list any supplements and/or medications you are currently taking.Are you allergic to any foods, fruits, vegetables or plants?* Yes No Are you allergic Latex?* Yes No Have you ever received any of the following treatments? Facial Microdermabrasion Laser Surgery Chemical Peel Waxing Lash/Brow Tint Laser Hair Removal Vein Treatment What is the purpose of seeking facial services?How did you hear about us? Google Social Media (Facebook, Twitter) Groupon Referral Other Please let us know who referred you Please list "Other" source [/raw]
