Name
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Birthdate
MM
DD
YYYY
In case of an Emergency who should we contact?
First Name
Last Name
Phone
(###)
###
####
How did you hear about SkinByGabby?
*
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
Yes
No
2. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly
3. Do you smoke (cigarettes, recreational drugs, vape)?
Yes
No
4. Do you exercise regularly?
Yes
No
5. Do you have any allergies?
Latex, nickel, lavender, pineapple, etc
Yes
No
If yes, please list allergies
6. Have you ever had an allergic reaction to Aspirin?
Yes
No
7. Do you sunbathe or use tanning beds?
Yes
No
8. Have you waxed the treatment area within the last 72 hours?
Yes
No
9. Do you use Retin-A, Renova, Adapalene, Differin, Tazorac, Avage, EpiDuo, Ziana or any other prescription skin products?
Yes
No
If yes, please list which ones
10. Have you taken isotretinoin (acutane) within the last 6 – 12 months?
Yes
No
11. Are you currently using any products that contain the following ingredients? *
Retinol
Vitamin A derivatives
Any hydroxyl acid products
Any exfoliating scrubs
12. Do you ever experience these conditions on your skin?
Flakiness
Tightness
Obvious dryness
13. What SPF sunscreen do you use on your face?
14. Do you burn easily in moderate sunlight?
Yes
No
15. Have you had any direct sun exposure within the last 72 hours?
Yes
No
16. Do you have a tendency to redness?
Yes
No
17. Do you have metal implants, pacemaker, electronic implants and/or body piercings? *
Yes
No
18. Are you prone to cold sores or fever blisters?
Yes
No
19. Are you currently experiencing
any cold sores, fever blisters, contagious disease (e.g. fungus, ringworm on the scalp/body/hands, head/body lice, lesions, athlete’s foot, warts), folliculitis (inflammation of hair follicles)
Yes
No
20. Do you ever experience burning, itching or stinging sensations on your skin?
Yes
No
21. Are you pregnant or trying to become pregnant?
Yes
No
Does not apply
22. Are you lactating?
Yes
No
Does not apply
23 Males. Do you have any shaving challenges?
Yes
No
Does not apply
24. Lets be social! Do you grant permission to be video recorded, photographed and be featured on social media?
Yes, I love the attention
No, I’m camera shy
25. I consent to have read treatment contraindications and policies
*
Yes
No
Todays' date
MM
DD
YYYY