Name____________________________________Birthday_______________________Date_______________

Address___________________________________________________________________________________

Home phone______________________cell________________________email__________________________           

Do you wash your face with soap or cleanser- circle one.

            Do you moisturize?     yes or no

            Do you use Glycolic acid?   yes or no

            Do you use Retin A? yes or no

            Have you ever taken Accutane? yes or no

            Are you allergic to anything?   Nuts    iodine    sulfur

            Does your skin burn or itch? yes or no

            Do you experience redness or irritation?  yes or no

            What skincare do you use__________________________________________________

            When was your last Facial__________________________________________________

What concerns do you have with your skin?__________________________________________

                        Your Signature_____________________________________________________

By signing this Chart you give me permission to touch and treat your skin.