Facial Consent Form

Exact information is mandatory to evaluate my skin:

"*" indicates required fields

Am I presently taking any medications?*
Am I presently under the care of a doctor and/or dermatologist?*
Am I taking Accutane, Retin A, Adapalene, Renova, or other prescription skin products?*
Do I smoke?*
Have I undergone radiotherapy or chemotherapy?*
Have I undergone any of the following treatments: laser, medical dermabrasion, epidermabrasion, chemical peeling?*
Do I sunbathe or use tanning beds?*
Do I wear contact lenses?*
Am I epileptic?*
Do I exercise or play sports?*
Am I pregnant, trying to become pregnant, or lactating?*
Am I menopausal?*
Do I suffer from any of the following: Heart-pacemaker, thyroid, hormonal imbalances, high or low blood pressure?*
Do I suffer from: rosacea, eczema, psoriasis?*
DD dash MM dash YYYY
This field is for validation purposes and should be left unchanged.