review
Please enable JavaScript in your browser to complete this form.
Loading
Please enable JavaScript in your browser to complete this form.
Client Information - Step 1 of 4
Name *
Date of Birth *
Address *
Treatment *

Please fill out only the selection relevant to the treatments you are interested in.

1: Do you have any known allergies? *
2: Are you currently taking any medications? *
3: Do you have any of the following medical conditions? *
4: Are you pregnant or breastfeeding? *
5: Have you used Accutane or any other prescription acne medications within the last year? *
6: Do you smoke or use tobacco products? *

Chemical Peel:

1: What are your primary skin concerns? *
2: Are you currently using any skincare products containing retinol, glycolic acid, salicylic acid, or other exfoliants? *
3: Do you have a history of pigmentation issues (e.g., melasma, post-inflammatory hyperpigmentation)? *
4: Do you have any history of cold sores, especially around the mouth? *
5: Do you have a history of keloid scarring or poor wound healing? *
6: Have you had a chemical peel before? *

Microneedling:

1: What are your primary skin concerns? (copy) *
2: Have you had microneedling before? *
3: Do you have a history of keloid scarring or poor wound healing? *
4: Have you had any recent cosmetic procedures (e.g., Botox, fillers, laser treatments) within the last month? *

Dermaplaning:

1: What are your primary skin concerns? (copy) (copy) *
2. Have you had dermaplaning before? *
3: Do you have active acne, cold sores, or other skin infections? *
4: Are you currently on any blood thinners or anticoagulants? *

24K Gold Facial Section:

1: What are your primary skin concerns? *
2: Have you had a 24K Gold Facial before? *
3: Do you have any known sensitivities or allergies to gold-based products or other skincare ingredients? *
Have you been informed about pre-treatment guidelines for each treatment? *

If yes, please acknowledge the following instructions:

For Chemical Peel: Avoid excessive sun exposure, discontinue retinoids and exfoliants for at least one week prior.

For Microneedling: Refrain from tanning, sun exposure, and avoid retinoids or exfoliating products 3-5 days prior.

For Dermaplaning: Avoid waxing, threading, and harsh exfoliants on the treatment area for at least 1-2 weeks prior.

Acknowledgment & Consent:

Date *
This combined template should cover the necessary information and risks for each treatment, ensuring clients are well-prepared and informed.
Loading