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HYDRAFACIAL PRICING

REWARDS PROGRAM

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SKIN TYPING MATRIX

Name *

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My ethnic origin is closest to:

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My eye color is:

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My natural hair color at age 18 was:

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The color of my skin that is not normally exposed to sun is:

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If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will:

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When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artificial tanning creme (sunless tanners):

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Printable Skin Typing Matrix Form

MEDICAL FORM

Medical History *

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Male Female

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Please enter a valid email address.

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What skin issues are you concerned about and how long have you been concerned about these skin issues

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At what age did you notice this concern

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Are your present skin concerns getting more pronounced?

Yes No

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Have you ever been treated for this concern? If yes, when and what method?

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Are you currently taking medications for your skin concerns? If yes, what is it?

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What topical skin medications or products are you currently taking?

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Have you ever had laser/BBL/IPL hair removal?

Yes No

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Have you ever used the following hair removal methods in the past 6 weeks?

Shaving Waxing Electrolysis Plucking/Tweezing Depilatories

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Have you ever had skin resurfacing or rejuvenation or chemical peels?

Yes No

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Have you ever had treatments for pigmented lesions?

Yes No

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Do you form thick or raised scars (keloids) from cuts or burns?

Yes No

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Do you experience hyperpigmentation (redness) from burns, cuts, insect bites?

Yes No

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Have you ever had cold sores or fever blisters?

Yes No

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Skin types choices when exposed to the sun for about 1 hour with no problem:

Always Burn Rarely Burns Always Burns, Sometimes Tan Brown, Moderately Pigmented Sometimes Burns, Always Tans Black Skin

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When were you last exposed to the sun or tanning booth?

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Do you use self or sunless tanners?

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Are you planning a vacation in the sun?

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Do you smoke?

Yes No

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Do you consume alcohol daily? If yes, how much?

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Do you wear contact lenses?

Yes No

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Are you currently under the care of a physician? If yes, what for?

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If you selected other above, please specify.

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Please list any allergies (food, plants, anesthesia, drugs) and what reactions you have to those allergens.

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If you selected other above, please specify.

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Are you taking herbal preparations or vitamins? (St. John's Wort, Vitamin E, Fish Oil)

Yes No

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Are you pregnant or trying to become pregnant?

Yes No N/A

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Digital Signature (Please type name) *

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I have answered the questions contained in this questionnaire to the best of my knowledge. I understand that it is my responsibility to inform my practitioner of my current health conditions while seeking treatment as a client. I will update this information as it occurs.

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Printable Medical Form

SCHEDULE A CONSULTATION

Provide us with information about the services you are interested in and what types of skin imperfections you are dealing with so we may better assist you.

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