Name
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First Name
Last Name
Phone
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Email
*
Birthdate
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In case of an Emergency who should we contact?
First Name
Last Name
Phone
(###)
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How did you hear about SkinByGabby?
*
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
2. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly
3. Do you smoke (cigarettes, recreational drugs, vape)?
4. Do you exercise regularly?
5. Do you have any allergies?
Latex, nickel, lavender, pineapple, etc
If yes, please list allergies
6. Have you ever had an allergic reaction to Aspirin?
7. Do you sunbathe or use tanning beds?
8. Have you waxed the treatment area within the last 72 hours?
9. Do you use Retin-A, Renova, Adapalene, Differin, Tazorac, Avage, EpiDuo, Ziana or any other prescription skin products?
If yes, please list which ones
10. Have you taken isotretinoin (acutane) within the last 6 – 12 months?
11. Are you currently using any products that contain the following ingredients? *
12. Do you ever experience these conditions on your skin?
13. What SPF sunscreen do you use on your face?
14. Do you burn easily in moderate sunlight?
15. Have you had any direct sun exposure within the last 72 hours?
16. Do you have a tendency to redness?
17. Do you have metal implants, pacemaker, electronic implants and/or body piercings? *
18. Are you prone to cold sores or fever blisters?
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)
20. Do you ever experience burning, itching or stinging sensations on your skin?
21. Are you pregnant or trying to become pregnant?
22. Are you lactating?
23 Males. Do you have any shaving challenges?
24. Lets be social! Do you grant permission to be video recorded, photographed and be featured on social media?
25. I consent to have read treatment contraindications and policies
*
Todays' date
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