New Client Consult Form Step 1 of 3 - Contact Info 33% Name First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Birthdate* MM slash DD slash YYYY Please answer these questions to help us provide the best service for your skin.Within the last year, have you had any health problems that have affected or could affect your skin?* Yes No If yes, please specify:List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly.Do you wear contact lenses?* Yes No Do you have metal implants, a pacemaker or body piercings?* Yes No Do you have any allergies?* Yes No If yes, please specify:Do you have sinus problems?* Yes No Have you ever experienced claustrophobia?* Yes No What are your specific concerns/challenges with your skin?What skin care products are you currently using?* Soap Cleanser Toner Moisturizer Masque Exfoliant Eye Products Other Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?* Yes No Have you been waxed within the last 72 hours?* Yes No Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?* Yes No Are you currently using any products that contain the following ingredients? Glycolic Acid Lactic Acid Any Exfoliating Scrubs Hydroxy (AHAs, BHAs) Vitamin A Derivatives (i.e., Retinol Please Specify if any of the following apply to you: Pregnant Tying to Become Pregnant Lactating Menstruating Pre-menstrual I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.* Yes Signature* Type your full name hereNameThis field is for validation purposes and should be left unchanged. Services Select a Treatment Specials Save on Skincare