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Treatment Consent Form

Please answer the flowing questionnaire thoroughly and completely,as this provides a better understanding of your general health, lifestyle, and skincare concerns; thereby enabling the best skin care program to be customized for your individual needs.

Do you have allergies and eczema, sun sensitivity, herpes simplex
Do you have active herpes simplex
Do you have warts on the face?
Have you used Accutane within the last six months?
Have you had any recent surgery or other wounds that are healing on the face?
Have you had anything frozen off at the dermatologist recently?
Have you had previous peels if yes when was the most recent?
Have you in the last week had waxing, electrolysis, eyebrow micro blading, permanent make up hair color, permanent hair straightening treatment, micro needling?
Do you use Retin-A or any other Retin-A derivative?
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