BEST VIEWED ON A DESKTOP OR LAPTOP COMPUTER PERSONAL INFORMATIONPlease fill out all required fields. Full Name * Date of Birth * Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Phone Number * Email * Age * MEDICATION HISTORYPrescribed, over-the-counter, and recreational drugs and medications (past and present). Check all that apply. Antibiotics Yes When How long Accutane Yes When How long Benzoyl Peroxide Yes When How long Differin Yes When How long E-mycin-T Yes When How long Rein A Cream or Gel Yes When How long Tazorac Yes When How long Cleocin-T Yes When How long Azelex Yes When How long Sulphur Yes When How long Avita Yes When How long Testosterone Yes When How long Disufuram Yes When How long Progesterone Yes When How long Copazone Yes When How long Minosine Yes When How long Cortisone Yes When How long Androstendione Yes When How long Cyclosporin Yes When How long Thyroid Medication Yes When How long Quinine Yes When How long Dilantin Yes When How long Lithium Yes When How long Isoniazid Yes When How long Immuran Yes When How long Danzol Yes When How long Gonadotrophin Yes When How long Steroids Yes When How long Marijuana Yes When How long Cocaine / Speed Yes When How long Other Yes What & when How long SKIN SERVICES HISTORYWhat else have you done for your skin? Check all that apply. Glycolic Acid Peels Yes When Dermabrasion Yes When Microdermabrasion Yes When Chemical Peels Yes When Plastic Surgery Yes When Skin Cancer Removal Yes When Facial Waxing Yes When Electrolysis Yes When Laser Hair Removal Yes When Other Yes What & when PRODUCTS CURRENTLY BEING USEDPlease list product names. Cleanser(s) Toner(s) Serum(s) Mask(s) Moisturizer(s) Foundation(s) Exfoliant(s) Acne medication(s) SPF Blush Shampoo Conditioner Any product type(s) not listed LIFESTYLE CONSIDERATIONSHave you ever had ANY reaction to any of the above products or anything you have ever put on your face? YesNo If yes, which product(s)? Describe your reaction. Are you allergic to any of the following: SulphurAspirinLatex Do you use fabric softener or fabric sheets in the dryer? YesNo Do you pick at your skin? YesNo Do you smoke? YesNo Do you work around chemicals, tars, oils or inks? YesNo Do you regularly eat or ingest any of the following: KelpSeaweedSushiSaltFast foods Are you currently under a lot of stress? YesNo Do you use hair gel? YesNo If yes, what brand? WOMEN ONLYAre you on birth control pills? YesNo If yes, which brand? Are you taking Dep Provera shots? YesNo Are you pregnant or nursing? YesNo SKIN CARE CONCERNSCheck all that apply: BlackheadsWhiteheadsPimples / PustulesCystsOily skinDehydrated skinDark spotsAge spotsBroken capillariesFine lines / wrinklesDry, flaky skinSensitive skinRazor bumpsShaving irritationAcne rosacea Describe your skin type: OilyNormalSensitiveOily / DryDry MEDICAL HISTORYCheck all that apply. DiabetesEczemaPsoriasisHepatitisCancerHIV Positive / AIDSHormone problemsHysterectomyOvary(ies) removedHemophiliaLupusThyroid problemsHerpes SimplexAnemiaHigh blood pressure Are you under a dermatologist's care? YesNo If yes, name of doctor: MISCELLANEOUSOccupation: How did you hear about us? VERIFICATIONPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank
