Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tel./Cell *

(###)

###

####

Within the last year, have you been under a dermatologist or other physician’s care? *

Yes

No

Are you wearing contact lenses to your appointent? *

Yes

No

Do you have sinus problems? *

Yes

No

Do you have a tendency to redness? *

Yes

No

Are you or have you been on Accutane within the past 6 months? *

Yes

No

Have you ever experienced claustrophobia? *

Yes

No

Have you ever had an allergic reaction to Aspirin? *

Yes

No

Are you prone to cold sores or fever blisters? *

Yes

No

Have you had Botox or Dermal Fillers within the last 2 weeks? *

Yes

No

10 What skin care products are you currently using? *

soap

cleanser

toner

moisturiser

masque

exfoliator

eye products

none

Have you had chemical peels, laser, microdermabrasion or any resurfacing treatments in the last month? *

Yes

No

Have you waxed within the last 72 hours? *

Yes

No

Do you sunbathe or use tanning beds? *

Yes

No

Please read ALL of the following statements carefully and indicate your understanding and acceptance: *

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Shikha of Skin Oasis

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory

I have not had a peel treatment of any kind within 14 days of my treatment at Skin Oasis. I understand I cannot have another treatment until recommended by Shikha at Skin Oasis. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Shikha

I understand that clinical photographs may be taken at each appointment and are considered a confidential and essential component of my medical record. The photographs will not be used for or disclosed for any media purposes without my signed permission on a separate media consent form

I will avoid heat, saunas, hot tubs and sweaty activity for 24 hours; this includes exercise of any kind

By my electronic signature below, I give consent to receive treatments at Skin Oasis and have read and completed this questionnaire truthfully

Date *

MM

DD

YYYY