Name * First Name Last Name Email * Date of Birth MM DD YYYY Skin Condition * Please select what best describes your current skin condition Normal Dry Oily Acne Other How does your skin heal? * Please select what best describes your healing process. Fast Pigments Scars Slow Other What skin care products are you currently using? Please include the product name and specific brand. Describe your current skin care routine. How are you utilizing the products described in the previous question? Are you taking any medications that are related to cosmetic or skin improvement? Please consult your doctor for any potential prescription drug interactions that may occur. Please let your doctor know about services and treatments provided by your esthetician . Do you have any of the following conditions? Please select any / all applicable conditions that may impact services Cancer Hypotension Pacemaker Thyroid Disorder Hormonal Imbalance Hepatitis A/B/C Depression/Anxiety Rosacea Bruise Easily Immune Disorder Keloid Scarring Skin Disease Menopause Varicose Veins Hypertension Metal Implants Diabetes Heart Disease Hysterectomy Epilepsy or Seizures HIV/AIDS Migraines/Headaches Psoriasis Eczema Spinal Cord Injury Lupus Blood Clot Disorder Fibromyalgia Circulation Disorder Other Are you pregnant? * Yes No Are you planning to be pregnant? * Yes No Are you on any form of contraceptive? * Please put "None" if not applicable Are you breast feeding? * Yes No Do you drink caffeinated drinks? Yes No Emergency Contact Name * First Name Last Name Emergency Contact Number * Anything else you want to tell your esthetician? I will tell my esthetician if I have any changes in my physical health that may impact services provided. * Yes Thank you!