Skin Consultation Form

Have you in the past or present or had any of the following problems?

.

Have you had plastic surgery? Required

Yes

No

If yes, did it achieve the results you want?

Yes

No

Do you suffer from claustrophobia or anxiety? Required

Yes

No

Ethnicity: Required

Caucasian

African American

Asian

Other

Check the areas of concern you would like to improve in your skin: Required

.

Have they achieved the results you want? Required

Yes

No

Do you have a tendency to keloid scar? Required

Yes

No

Have you had a skin peel in the last 2 years? Required

Yes

No

Have you been under a physician’s care during the past 3 years? Required

Yes

No

Are you currently taking medication? Required

Yes

No

Are you currently taking Accutane or Roaccutane? Required

Yes

No

Are you taking any dietary or Herbal Supplements or Vitamins? Required

Yes

No

Do you use sunscreen daily? Required

Yes

No

Check the areas you would like more information on or are interested in:

Cellulite

Body sculpting/Firming

Scarring/pigmentation

Alternative hair removal

.

Weight loss

Stretch marks

Ingrown hairs

Heavy Callouses & Cracked Feet

How much water, coffee/tea (caffeine) do you drink daily? Required

Water

Caffeine

Alcohol

Have they achieved the results you want?

Yes

No

S V

DMK- Client Record/ Confidential Analysis

All information collected is for the benefit of treatments. Your details are kept strictly confidential at all times.

Client Details

Medical History

Shipping Address:

Are you currently using Retin-A, Retinal, AHA or any peeling agent? If so:

Skin

Medication

Body

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