Skincare Form/Waiver

Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your current stress level? *

High

Medium

Low

If you have been treated for any of the following please check the box *

Acne

Depression

Skin Disease

High Blood Pressure

Cold Sores

Diabetes

Cancer

Epilepsy

Pacemaker/ Defibrillator/ ICD

None

Are you pregnant? *

Yes

No

Are you on hormone therapy? *

Yes

No

Are you prone to cold sores? *

Yes

No

Do you smoke? *

Yes

No

Are you on prescription skincare from a dermatologist? *

Yes

No

Do you take supplements? *

Yes

No

Have you ever had skin cancer? *

Yes

No

Do you use sunblock on your face daily? *

Yes

No

Sometimes

Do you use tanning beds? *

Yes

No

Do you get professional facials? *

Yes

No

How do you feel about the overall quality of your skin? *

Very Happy

Good

Unhappy

Your skin type is: *

Normal

Dry

Dehydrated

Oily

Acne

Acne Prone

Rosacea

For massage during treatment what pressure do you prefer? *

Light

Medium

Deep