First step: complete the following form Name Current day Address City State AlabamaAlaskaArizonaArkansasCaliforniaNorth CarolinaSouth CarolinaColoradoConnecticutNorth DakotaSouth DakotaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew JerseyNYNew HampshireNew MexicoOhioOklahomaOregonPennsylvaniaRhode IslandTennesseeTexasUtahVermontVirginiaW.V.WashingtonWisconsinWyoming Zip Email Cell phone Date of Birth Emergency Contact Phone Are you pregnant? Yes No If yes, how far along? Do you have any of the following health conditions? AIDS/HIV Cancer Diabetes Heart Problems Hepatitis Hi/Low Blood Pressure Lupus Recent Surgeries Strokes None Please list any other health conditions not listed above: Are you currently using any of the following? Retin A/Renova Glycolic Acid / Alpha Hydroxy Acid Accutane Topical Vitamin C Hydroquinone Hormone Replacement Therapy Birth Control Pills Sunscreen / Sun Block None If yes, please list the names of any prescription medication? Are you using or have ever used any medications for acne? Yes No If yes, how long has it been since you last used acne medication? Do you suffer from Cold Sores? Yes No If yes, do you take medication? Yes No Do you smoke? Yes No Do you tan? Yes No Have you had facials before? Yes No Have you had electrolysis, laser hair removal, or waxing in the last week? Yes No What skin care products are you currently using? Have you ever had an allergic reaction to any of the following? Cosmetics Medication Food Animals Sunscreens Iodine Pollen Skin Products Essential Oils Nuts Alpha Hydroxy Acids Fragrance Shellfish Latex Aspirin Other None If yes to any of the above, please explain? Have you had any of the following? Cosmetic Surgery Botox Injections Skin Cancer Dermatitis Keloid Scarring Laser Resurfacing Chemical Peels Other None If yes to any of the above, please state when your last treatment was: What areas of concern do you have regarding your skin? Breakouts / Acne Blackheads / Whiteheads Excessive Oil / Shine Rosacea Broken Capillaries Sun / Liver / Brown Spots Enlarged Pores Uneven Skin Tone Sun Damage Wrinkles / Fine Lines Dull / Dry Skin Flaky Skin Dehydrated Other Is there any other information I should know before beginning your treatment? It's your responsibility to inform Gloria G. of any pre-existing and all health conditions. It's also your responsibility to inform Gloria G. of any discomfort during any session. I understand and accept any risk of which I have been advised associated with the agree upon skin treatment. I release Gloria G. from all liability arising from an injury and/or damage from failure to inform Gloria G. of any pre-existing conditions, limitations, specific sensitives, and/or any discomfort during the treatment. I agree to keep Gloria G. updated as any changes in medical profile. I accept the above statement Send
