Name *

First Name

Last Name

Date

MM

DD

YYYY

Have you ever attended a dermatologist?

Yes

No

Have you ever had a skin allergy/reaction after a treatment

Yes

No

Do you have sensitive skin

Yes

No

Do you have a history of cold sores/ lip herpes

Yes

No

Have you undergone any cosmetic procedures

Yes

No

Do you bruise easily

Yes

No

Do you suffer from or have a history of moles / keloid scars / warts

Yes

No

Do you sunbathe or use the sun beds regularly

Yes

No

Could you be pregnant/ planning a pregnancy or breastfeeding?

Yes

No

During pregnancy did you suffer from hyper pigmentation or masking

Yes

No

N/A

Do you use any topical skin creams/treatment?

Yes

No