Skin Care History Questionnaire and Waiver

Name: ______Date: ______

Address: ______

City: ______State: ______Zip Code: ______

Cell Phone: ______Date Of Birth: ______

Email Address: ______

Have you seen a dermatologist in the past year? Yes ______No ______

If yes list dermatologist name and reason for visit ______

______

Are you currently taking any medications? Yes ______No ______if yes, please list ______

Please check if you or have used the following products in the last 7 days please write YES or NO ______Benzoyl Peroxide (BP)

______Tretinoin (Retin A, Retin –A Micro®, Renova

______Glycolic Acid (AHA)

______Adepalene (Differin®)

______Lactic Acid (AHA)

______Azelaic Acid ( Azelex®,Finacea™)

______Tazarotene (Tazorac®)

______Salicylic Acid

______Isotretinoin (Acuutane)

______Vitamin A

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Please circle the following conditions you have or had experience:

HIV Metal plate Diabetes Contact lenses anemia Cancer Varicose veins Seizures Blood disorders Headaches Asthma hepatitis high Low blood pressure Cold sores Lupus thyroid disease Do you take nutritional supplements? Yes ______No ______Do you exercise? Yes ______No ______Do you have a tendency to scar? Yes ______No ______Allergies Have you ever had an allergic reaction to any of the following please write YES OR NO ______Aspirin or Salicylates ______Grapes ______Milk Products ______Latex ______Fish, marine or iodine ______Skin care Products ______Apples ______Nuts ______Citrus If yes have you been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva? ______Are you being treated for Hepatitis? Yes ______No ______Are you on hormone replacement therapy? Yes ______No ______Are you presently taking birth control pills? Yes ______No ______Are you pregnant or nursing? Yes ______No ______Are you currently having skin care treatment? Yes ______No ______If yes, what type of treatment ______(please Turn over Page) Have you had any of the following in the last 14 days please write YES or NO ______Facial Cosmetic Surgery ______Chemical Exfoliation (peels) ______Botox Injections ______Extractions ______Collagen Injections ______Permanent Cosmetics ______Skin Cancer ______Waxing ______Dermatitis ______Laser Hair Removal ______Keloid Scarring ______Microdermabrasion ______Laser resurfacing ______Fillers Home Care

What skincare products are you currently using at home? Cleanser ______Vitamin C ______Toner ______Exfoliates/ Scrubs ______Moisturizer ______SPF ______Retinol/Tretinol______Glycolics/Salicylics______

Please check if you are currently using any of the following products?

______Benzoyl Peroxide (BP) ______Tretinoin (Retin A, Retin –A Micro®, Renova

______Glycolic Acid (AHA) ______Adepalene (Differin®)

______Lactic Acid (AHA) ______Azelaic Acid ( Azelex®,Finacea™)

______Resorcinol ______Tazarotene (Tazorac®)

______Salicylic Acid ______Isotretinoin (Acuutane)

______Sulfur ______Vitamin A

Sun Protection Do you use a sunscreen? Yes ______No ______

What level of protection? ______

Do you sunbathe or participate in outdoor activities? Yes ______No ______

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Do you tan in a tanning booth? Yes ______No ______

Have you tanned in a tanning booth in the last 14 days? Yes ______No ______

Have you had any direct sun exposure in the last 14 days? Yes ______No ______

When exposed to sun do you:

______Always burn, never tan ______Sometimes burn, sometimes tan

______Always burn, sometimes tan ______Always tan

Do you feel your skin is sensitive? Yes ______No ______

What skin conditions do you want to improve?

____ Acne and or breakouts ____ Uneven Tone

____ Facial Scarring Other ______

____ Hyperpigmentation (freckles, age spots)

____ Enlarged pores

____ Fine Lines and Wrinkles

____ Rosacea

Certain services should not be performed with certain medical conditions. I have stated all my known medical conditions and answered all questions honestly on the medical history form and agree to update Sage Spa 431 LLC as to any changes. I acknowledge that the therapists at Sage Spa do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services of

Sage Spa 431 LLC. I hereby release, discharge and waive any and all claims against Sage Spa 431 LLC and each of their partners, employees, representatives or any person(s) performing services at Sage Spa 431 LLC, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document, understand that it affects my legal rights and agree to its terms.

Signature: ______Date: ______