Name *
Name
Address
Address
Phone *
Phone
Birthday *
Birthday
If yes, please explain.
Have you been under the care of a physician, dermatologist or other medical professional within the past year? *
if yes, please explain
Any Recent surgery, including plastic surgery, and c-section *
If yes, please explain
Any skin cancer
If yes, please explain
Are you on any medications *
If yes, please explain
Are you allergic to anything
if yes, please explain
(please provide additional information in the space provided)
Are you pregnant?
Do you have a sexually transmitted infection? *
If yes, please explain
Have you been exposed to the sun or use a tanning bed in the last 48 hours? *
Are you using Retin-A®, Accutane®, Alpha Hydroxy, Tetracycline or any other acne/skin medications or products? *
if yes, please list the medications
Have you received any Botox® or Derma-brasion treatments recently? *
If yes, please explain
Do you have diabetes, phlebitis, eczema, or psoriasis? *
If yes, please explain
Is there anything else that I need to know to better serve you?
If yes, please explain
THE LEGAL STUFF *
THE LEGAL STUFF I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform Tiffany of ME Beauty, LLC of my current medical or health conditions and to update this history. The treatment I receive here are voluntary and I release ME Beauty, LLC and or Tiffany R. Piggee' from liability and assume full responsibility thereof.