Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Phone *

(###)

###

####

Have you taken Accutane within the past 12 months? *

YES

NO

Have you recently received any exfoliating treatments or chemical peels? *

YES

NO

Are you pregnant, diabetic or receiving cancer treatments? *

YES

NO

Have you used a tanning bed or experienced prolonged sun exposure within the past 24 hours? *

YES

NO

Do you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins, or any skin sensitivities? *

YES

NO

Are you using acne medication (prescribed or over the counter) including Retin-A, Differin, Tazorac, Atraline, or other retinoids? *

YES

NO

Do you have AIDS, Lupus or other chronic conditions that may compromise the skin barrier? *

YES

NO

*

By signing this authorization form, you declare that the answers given are true and completed to the best of your knowledge. False or misleading answers can lead to complications and/or undesirable results.

Digital Signature *

First Name

Last Name

Date *

MM

DD

YYYY