Name___________________________________________________________________________Date_____________________
Address__________________________________________________________________________________________________
Home Phone_________________________Work Phone_________________________Cell Phone_________________________
Email_______________________________Referred By:______________________________Date of Birth__________________
List all allergies (medicines, food, environment, etc.):_____________________________________________________________
List all medicines and vitamins you are currently taking:___________________________________________________________
Have you, or are you currently using:
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Accutane ®
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Retin-A ®
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Benzol Peroxide
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Other topical skincare medications:
____________________________________ How long?______________________ Last time used?______________________
Have you had any facial treatments?
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Facials
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Waxing
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Chemical Peels
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Microdermabrasion
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Laser
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Injectables
Facial Surgery? If yes, list type of treatment and dates:____________________________________________________________
Have you:
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Used a tanning bed?
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Experienced sunburn? If yes, how long ago and severity?__________________________
Check the following that apply to you:
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Heart Problems
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Diabetic
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Cancer
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Cold Sores
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Psoriasis
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Eczema
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Smoke
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High Blood Pressure
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Hormone Imbalance
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Pregnant
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Claustrophobic
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Wear Contact Lenses
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Drink Alcohol
Please list any infectious diseases you may have:_________________________________________________________________
Please list any additional information that will help better serve you:_________________________________________________
Please check the following that best describes your skin:
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Dry
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Oily
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Normal
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Combination
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Sensitive/Redness
What concerns would you like to address about your skin?
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Signs of Aging
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Fine Line/Wrinkles
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Acne
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Redness
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Broken Capillaries
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Age Spots
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Dryness
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Sun Damage
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Loss of Firmness/Elasticity
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Dullness
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Breakouts
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Skin Discoloration
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Large Pores
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Blackheads
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Other:_____________________________________________________
What would you most like to improve about your skin?____________________________________________________________
Check the following products you currently use:
□
Cleanser
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Toner
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Moisturizer
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Serum
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Exfoliant
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Masque
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Eye Care
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Lip Care
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Sunscreen
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Other:___________________
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Brands:___________________________________

I understand that chemical exfoliation is a safe and highly effective treatment, but may cause some individual sensitivity

 and/or allergic reaction to one or more ingredients.
I understand that this treatment contains salicylic acid. I am not allergic to aspirin.
I understand that this treatment can not be performed on dermatitis; this includes rashes, open wounds, eczema & psoriasis.

I consent that one week prior to & after treatment, I have avoided electrolysis, waxing, depilatory creams & laser.

I consent that 48 hours prior to treatment and 24 hours after, I have avoided Accutane ® , Renova ® , Retin-A ® , Tazorac ® ,
Differin ® , Renova ® , AHA/BHA, prescription Benzol Peroxide, or any exfoliating products that are drying or irritating.

I understand that during and after the process, there can be a warm, tingling, and sometimes burning sensation, as well as redness, pinkness and possible soreness, peeling and inflammation.

I understand that picking and pulling the skin may cause pigment or scarring.

I acknowledge that I have avoided sun exposure 24 hours before and after treatment and will use a daily SPF of 30.

Chemical exfoliation treatments addresses hyper-pigmentation, acne/breakouts, excessive oiliness, redness, dryness, fine lines/wrinkles, uneven skin texture, pore congestion/size, scarring, firmness, collagen production, radiance and glow.

I acknowledge that there are no guaranteed results, and could have an increase in uneven color or pigment.

I understand that to achieve maximum results, I may need several treatments and use home care products.
I confirm to the best of my knowledge, that the answers I have given are correct, and that I have not withheld any information that may affect the outcome of my treatment. This information is intended for each service received and is the guest’s responsibility to notify Nicole Visee of NV Skin Therapy of any changes to the above information.
I understand and assume all risks and will not hold Nicole Visee or NV Skin Therapy responsible for any services or outcomes/damages received at NV Skin Therapy.
This information is confidential and is necessary to evaluate and best meet your proper skincare treatment and at home regime.
Thank you for choosing Nicole Visee of NV Skin Therapy for all your skincare needs.
Guest’s Signature___________________________________________________________Date_______________________
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