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First name
Last name
Date
Year
Month
Month
Day
Phone
Email
How did your hear about the RR?
Please list any Allergies.
Please list any medications.
What is the purpose of your visit?
Please check the box if it applies to you.
Thyroid disease
Pregnant/Breast feeding
Use of Vitamin A/Retinol
Prone to bruising
Pacemaker
Eczema
Metalic implants
Diabetes
Varicose veins
Sunburnt
HIV/AIDS
Psoriasis
Injury
Use of systemic steroids
Botox
Accutane
Use of Vitamin C
Use of AHA/BHA's
Birth control
Recent chemical peel
IPL/Photofacial
Laser
Microdermabrasion
Permanent makeup
Plastic Surgery
Plantar fasciitis
What are your primary skin concerns?
How often do you receive facials?
Are you susceptible to cold sores or sun blisters?
Yes
No
Do you have a tendency towards redness, rashes or hives?
Yes
No
Any past product reactions?
What product are you using on your skin?
Cleanser
Toner
Exfoliant
Mask
Treatment
Eye cream
Serum
Day cream
Night Cream
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