Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Date of Birth
MM
DD
YYYY
What are your skin care goals?
*
What are you skin care challenges?
If struggling with Acne, please specify, mild (occasional breakouts), moderate or severe (inflamed acne all over)
If you checked yes to any of these, please provide further information.
*
If Yes to cancer, are you in remission?
If Yes, please request authorization to treat from your physician and provide a copy prior to beginning Microcurrent treatment. If No, a current cancer diagnosis is a contraindication for treatment and we cannot proceed with the Microcurrent treatment.
Do you have any medical implants?
If yes, are you able to remove or turn your electrical/magnetic implant off for treatment?
Are you pregnant or planning to get pregnant?
Have you had Botox, Kybella or filler injections?
If Yes, when?
Are you wearing contact lenses?
Do you clench and/or grind your teeth?
Have you had surgery in the past 6 months?
If yes, when?
Have you been in an accident or suffered any injuries in the past two years?
If yes, please specify:
Do you have tension or soreness in a specific area?
If yes, please specify:
List current prescribed or over the counter medications (topical OR oral)
Any known Allergies?
If Other, please specify
Do you have any other medical conditions that we should know about?
*
If Yes, please specify:
Please describe your daily diet:
Do you follow a restricted diet?
*
How many times per week do you consume: Processed/Fast Foods
How many times per week do you consume: Fruits
How many times per week do you consume: Vegetables
Do you smoke?
*
What is your current stress level?
How many hours do you typically sleep each night?
Have you been over exposed to the sun or used a tanning bed in the last 72 hours?
Date
MM
DD
YYYY
Thank you for completing the questionnaire! I look forward to working with you to get your acne under control.
To schedule an appointment for a in person acne treatment, you must also complete this consent form .
