YES
NO
Laser procedures, chemical peels, dermabrasion, microdermabrasion
Light sensitive medication
Loose, thin, aged skin
Lymphatic disorder, inflammation of lymph vessels, lymphedema
Medication, list here:
Open Lesion/Wound
Phlebitis, varicose veins
Recent accident or serious injury
Recent surgical or dental procedure
Rosacea, telangiectasia/couperose
Retin-A, Retinol
Skin abrasions or lesions
Stage III or IV acne
Skin-lightening or bleaching agent
Sunburn
Swollen or infected tonsils
Thyroid conditions
Type I diabetic
Under medical care for an existing or suspected condition or disease
Viral infection, influenza
Other contraindication at discretion of skincare technician or medical practitioner:
If you answered YES to any of the above questions please explain:
My interest in skincare procedure is primarily for (i.e. skin rejuvenation, acne, hyperpigmentation, scarring, etc.):
Specify your areas of concern (i.e. eyes, forehead, etc.):
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? (CONTINUED)
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