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Skin Care Professional Name:
What is the reason for your visit today?
What special areas of concern do you have?
Which conditions would you like to improve?
Acne scarringAcneAge spotsEnlarged PoresFine lines & wrinklesHyperpigmentationBroken CapillariesStrectch MarksSurgical/Facial scarsOther
Have you ever had facial treatment in the past?
What was your experience?
How would you describe your skin?
How would you rate your skin?
Always burns, never tansAlways burns easily, tans slightlyBurns moderately – tans graduallySeldom burn – Always tans wellRarely burns – Deep tanNever burns – Deeply pigmented
Do you ever experience
Flakiness?Redness?Tightness?Excessive oily shine during day?
What is your present skin regimen?
Soap and water onlyMoisturizerCleanserExfoliationTonerSun Block every dayMasqueOther
Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?YesNo
If yes, what are they?
Do you blush easily? YesNo
If yes, what are the contributing factors? EmotionsFoodsTemperature changesOther
Do you Sun bathe?Use a tanning bed?
Have you ever had PeelsMicrodermabrasionFacial surgeryCosmetic SurgeryBotoxCollagen InjectionsLaser resurfacing
Are you under treatment for any current skin condition? YesNo
If yes, what?
Does your skin heal FastScarsPigments
Do you bruise easily? YesNo
Do you get sores/blisters (Herpes Zoster/Shingles)? YesNo
What medications/hormone replacement/vitamins do you presently take?
Have you ever used Accutane©Retin-A®Renova®Topical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy Acids
If yes, when and for how long?
Any personal or family history of skin cancer? YesNo
How would you describe your overall health? ExcellentGoodFairPoor
Have you ever had a reaction to CosmeticsMetalsMedicationFoodFragranceAirborne particlesOther
How many glasses of water do you consume daily?
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
1 - 3 cups4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you?
Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.
I , do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold harmless the skin care professional, Lorraine ‘RAIN’ Tabraham-Winter, LMT, Esthetician, SET, CFT, CPT; Rain's Therapeutic Massage & Skin Care, Inc., and the staff harmless from any liability for adverse reactions that may result from this treatment.
1.We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before.
2.If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.
I have read and understood all of the foregoing information