NV Skin Therapy

NV Skin Therapy

Consultation Questionnaire

Name______Date______

Address______

Home Phone______Work Phone______Cell Phone______

Email______Referred By:______Date of Birth______

Medical Information

List all allergies (medicines, food, environment, etc.):______

List all medicines and vitamins you are currently taking:______

Have you, or are you currently using: □ Accutane® □ Retin-A® □ Benzol Peroxide □ Other topical skincare medications: ______How long?______Last time used?______

Have you had any facial treatments? □ Facials □ Waxing □ Chemical Peels □ Microdermabrasion □ Laser □ Injectables Facial Surgery? If yes, list type of treatment and dates:______

Have you: □ Used a tanning bed? □ Experienced sunburn? If yes, how long ago and severity?______

Check the following that apply to you:□ Heart Problems □ Diabetic □ Cancer □ Cold Sores □ Psoriasis □ Eczema □ Smoke

□ High Blood Pressure □ Hormone Imbalance □ Pregnant □ Claustrophobic □ Wear Contact Lenses □ Drink Alcohol

Please list any infectious diseases you may have:______

Please list any additional information that will help better serve you:______

Skincare Information

Please check the following that best describes your skin: □ Dry □ Oily □ Normal □ Combination □ Sensitive/Redness

What concerns would you like to address about your skin? □ Signs of Aging □ Fine Line/Wrinkles □ Acne □ Redness

□ Broken Capillaries □ Age Spots □ Dryness □ Sun Damage □ Loss of Firmness/Elasticity □ Dullness □ Breakouts

□ Skin Discoloration □ Large Pores □ Blackheads □ Other:______

What would you most like to improve about your skin?______

Check the following products you currently use:□ Cleanser □ Toner □ Moisturizer □ Serum □ Exfoliant □ Masque

□ Eye Care □ Lip Care □ Sunscreen □ Other:______□ Brands:______

Consent and Waiver for Chemical Exfoliation (Peel)

·  I understand that chemical exfoliation is a safe and highly effective treatment, but may cause some individual sensitivity and/or allergic reaction to one or more ingredients.

·  I understand that this treatment contains salicylic acid. I am not allergic to aspirin.

·  I understand that this treatment can not be performed on dermatitis; this includes rashes, open wounds, eczema & psoriasis.

·  I consent that one week prior to & after treatment, I have avoided electrolysis, waxing, depilatory creams & laser.

·  I consent that 48 hours prior to treatment and 24 hours after, I have avoided Accutane®, Renova®, Retin-A®, Tazorac®, Differin®, Renova®, AHA/BHA, prescription Benzol Peroxide, or any exfoliating products that are drying or irritating.

·  I understand that during and after the process, there can be a warm, tingling, and sometimes burning sensation, as well as redness, pinkness and possible soreness, peeling and inflammation.

·  I understand that picking and pulling the skin may cause pigment or scarring.

·  I acknowledge that I have avoided sun exposure 24 hours before and after treatment and will use a daily SPF of 30.

·  Chemical exfoliation treatments addresses hyper-pigmentation, acne/breakouts, excessive oiliness, redness, dryness, fine lines/wrinkles, uneven skin texture, pore congestion/size, scarring, firmness, collagen production, radiance and glow.

·  I acknowledge that there are no guaranteed results, and could have an increase in uneven color or pigment.

·  I understand that to achieve maximum results, I may need several treatments and use home care products.

Disclosures

I confirm to the best of my knowledge, that the answers I have given are correct, and that I have not withheld any information that may affect the outcome of my treatment. This information is intended for each service received and is the guest’s responsibility to notify Nicole Visee of NV Skin Therapy of any changes to the above information.

I understand and assume all risks and will not hold Nicole Visee or NV Skin Therapy responsible for any services or outcomes/damages received at NV Skin Therapy.

This information is confidential and is necessary to evaluate and best meet your proper skincare treatment and at home regime. Thank you for choosing Nicole Visee of NV Skin Therapy for all your skincare needs.

Guest’s Signature______Date______