Do you have permanent makeup?
YesNo

Have you recently had facial or body waxing or used at home depilatories?
YesNo

Do you have extended outdoor plans in the next 7 days?
YesNo

Do you plan to participate in vigorous exercise in the next 72 hours?
YesNo

List all topical products applied in the last 7 days

List all prescription medications currently taken and in the past two weeks.

(Note: Patient MUST be o" Accutane for 3-6 months prior to peeling).

Have you recently undergone any surgery or laser treatments in the area to be treated?
YesNo

If yes, please provide detail

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, etc.)

How would you describe your skin?PIGMENTAGINGACNEROSACEAOTHER

Phone Number

Email Address