Your Name (required)
Date of Birth
Dermatologist / Physician
Your Email (required)
Dermatologist / Physician Phone
Emergency Contact Phone
1. Which conditions would you like to improve?
Acne ScaringEnlarged PoresBroken CapillariesOtherAcneFine Lines & WrinklesStretch MarksAge SpotsHyperpigmentationSurgical / Facial Scars
If other, please explain
2. Have you ever had facial treatments in the past?
What was your experience?
3. How would you describe your skin?
4. How would you rate your skin?
1- Always burns2 - Burns easily, tans slightly3 - Burns moderately, tans gradually4 - Seldom burns, always tans well5 - Rarely burns, deep tan6 - Never burns, deeply pigmented
5. Do you experience
Flakiness?Dryness?Redness?Excessive Oily Shine During Day?
6. What is your present skin regimen?
Soap & water onlyCleanserTonerMaskMoisturizerExfoliationSun block every dayOther
7. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?
If yes, what are they?
8. Do you blush easily?
If yes, what are the contributing factors?
9. Do you sunbathe or use a tanning bed?
If yes, which and how often?
10. Have you ever had
PeelsMicrodermabrasionFacial surgeryCosmetic surgeryBotoxLaser resurfacingCollagen injectionsNone of these
If any, how recently?
11. Are you under treatment for any skin condition?
If yes, what?
12. How does your skin heel?
13. Do you bruise easily
14. Do you get sores / blisters (Herpes Zoster / Shingles)?
15. What medications / hormone replacements / vitamins do you currently take?
16. Have you ever used any of the following medications?
DifferinTazaracRenovaAlpha Hydroxy AcidsAccutaneRetin-ATopical AntibioticsHydorquinoneNone of these
If yes, when and how long?
17. Any personal or family history of skin cancer?
If yes, please provide details
18. How would you describe your overall health?
19. Have you ever had any of the following?
If yes, when?
Arthritis or Bursitis
Blood Pressure Reading
Diarrhea / Constipation
If yes, how often?
HIV / AIDS
Do you smoke?
Do you wear contact lenses?
20. Have you ever had a reaction to
Taking oral contraceptives?
Are you pregnant or trying to become pregnant?
Are you taking hormone replacement?
Do you experience hormone imbalances?
What do you shave with?
Do you experience skin breakouts?
Do you have ingrown hairs?
1. What is your stress level?
2. Do you normally sleep well?
3. Do you regularly exercise?
4. Do you have food intolerances?
5. Do you follow any special diet?
6. How many glasses of water do you consume daily?
7. How many cups of caffeinated beverages ( coffee, tea, soft drinks ) do you consume?
01 - 34 or more
In our treatment program, it may necessary to recommend alterations to or additions in your home care regimen; would that be okay with you?
Please Read and Initial
I fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand the aesthetician will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that the individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggest home product routine, I will consult with my aesthetician immediately.
I release and hold harmless the aesthetician, Pamela Cato, Cato Advanced Skin Care, and the staff from any liability for adverse reactions that may result from this treatment.
I have read and agree to the terms above *
1. We require 48-hours notice for cancellation. Cancellation for Monday must be phoned in on the Friday before.
2. If you are not satisfied with your service or products, please contact your skin specialist within 24 hours after your appointment so that the situation may be corrected.
It is our policy to provide you with the best professional service and products customized for your skin condition.
I have read and understood all of the forgoing information. Click and drag your mouse in thespace below to sign.
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