Client Data

Name

First

Last

Date Of Birth

Email *

Phone

Profession

Allergies: sulfa milk aloe grapes apples εσπεριδοειδες οστρακοειδη nuts other(describe) *

Yes

No

Skin diseases (psoriasis, eczema, rosacea etc.)*

Yes

No

Exposure to the sun for the last 2 weeks*

Yes

No

Self-tanning products for the last 2 weeks*

Yes

No

Hair removal in the last 4 weeks*

Yes

No

Use sunscreen daily with an SPF of 30 or greater*

Yes

No

Create παχές or elevated scars from the cuts, the burns*

Yes

No

Using products with retina-A or glycolic acid *

Yes

No

I certify that the medical information I have given is complete and accurate **

I agree

Current medication

Previous treatments (date and type)