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Age
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How often do you exercise?
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Occupation
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Are you a member of a Rewards Program?
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Do you want to be emailed monthly specials?
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Email
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How did you hear about us?
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Skin care concerns?
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Past medical history
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If so, please list:
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Are you currently taking any medications?
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If so, please list:
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Any allergies to medications?
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If so, please list:
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Do you currently smoke?
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How often do you drink Alcohol?
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Are you pregnant or lactating?
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Are you trying to become pregnant?
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Are you menopausal?
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Do you go to a tanning salon?
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Do you use sunscreen products regularly?
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Have you used any of topical Meds in past 7 days?
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Other topicals not listed above
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Do you get cold sores, fever blisters, outbreaks
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If yes, how many per year?
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Do you have any skin allergies?
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If so, please list
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Have you had any other cosmetic surgeries?
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If so, please list
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Are you currently taking any blood thinners?
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If so, please list
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Have you ever been to a Plastic Surgeon?
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If so, why did you see a Plastic Surgeon?
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Have you ever had cosmetic fillers
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If so, which?
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Have you ever had Botox or other neuromodulators
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If so, which?
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If yes, were you happy with your treatment?
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If no, please explain why
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Want to discuss Skin Care Products
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One thing you want to change about your skin?
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Other skin care concerns?
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