Your name: Your address: Contact information: Your birthday: What are your primary reasons for visiting today? What are you the most interested in today that I offer? Please check all that apply: Relaxation Results Corrective Facials Chemical Peels Derma-planing Home-care Products Treatment Plan Virtual Consultation In-Person Consultation Skin Prep Please list any medications, supplements or vitamins that you are taking (including herbs & essential oils) Are you using any of the following RX topical creams/oral medications from the dermatologist? Retin-A Tretinoin Differen EpiDuo Tazorac Accutane Clindamycin Spironolactone None Other Are you using over-the-counter Retinol in your anti-aging products? No Yes Do you have allergies to any food/medications/environment: No Yes Please check all that apply Aspirin Nuts Gluten/Wheat Ragweed Botanical Essential Oils Other Do you have any skin issues I should be aware of? Eczema Psoriasis Dermatitis History of Skin Cancer Other Skin Type: Normal Dry Oily History of Skin Sensitive Combo Can I use before/after photos if eyes are covered on social media? No Yes Are you wearing a Broad Spectrum SPF 45+ every day both indoors/outdoors? No Yes ***New data proves screen lighting and indoor LED lighting damages skin Do you have any of the following skin concerns? Please check any that apply: Hyperpigmentation/Melasma/Sun Damage Sensitivity/Rosacea/Redness/Flushing Aging/Fine Lines/Wrinkles/Collagen Loss Blackheads/Pimples/Breakouts Cystic Acne/Scarring Uneven Skin Tone/Uneven texture/Large Pores Impaired Barrier Function/Dryness/Dehydration Other Please describe your current A.M and P.M. skincare routine Are you willing to take my professional recommendations for home-care products to better your skin? No Yes ***Some of these products will be changed seasonally or as your skin changes into a maintenance plan No Sweating Rule Please check here to acknowledge that you are aware of the "No Sweating Rule" for the first 48 hours after a chemical peel treatment to avoid complications. How many steps are you comfortable using in your home-care regimen? Bare Minimum 1-3 A Good Start 2-4 A Complete System 4-6 Whatever it takes Are you ok with mild/minimal superficial peeling 3-5 days after treatment? No Yes Do you like a face and neck massage with your treatment? No Yes Are you pregnant or breastfeeding? No Yes Do you have a budget I need to work with? No Yes Do you have metal implants/pace maker? No Yes On a scale of 1-10, how committed are you to achieving maximum results for your skin in terms of home-care products and in-office treatments? 1 2 3 4 5 6 7 8 9 10 Consultation agreement I understand skin care services and recommendations are not a substitute for medical examination, diagnosis, or treatment. I have been advised that services provided by this spa could have unfavorable results including but not limited to allergic reaction, irritation, burning, lifting, redness, tingling, peeling, soreness, etc. I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services. I hereby confirm that I am not using any medication or product that may cause or contribute to any such injury/reaction and I will advise my esthetician during each visit if I should change medications/product that may affect my waxing or facial treatment. I will not hold Courtney Parkhill at Alpenglow Skin Spa responsible should there be any unfavorable results for this appointment or any future appointments. I understand that if I’m receiving a chemical peel, facial or derma-planing that for 48 hours after treatment, I will keep my skin cool and avoid extreme heat/cold that may otherwise cause hyperpigmentation or water blisters or an unfavorable peeling process. I will also follow post-procedure guidelines outlined by my esthetician to follow for 7 days after my treatment. I will not pick loose skin that could cause scarring, I will stay moisturized and wear a daily spf of 45 or higher and reapply throughout the day to protect my skin whether I’m inside (HEV lighting and screens) or outside (UVA/ UVB lighting). I understand that I do not need to peel to achieve the result. I also understand that direct sun exposure is prohibited while undergoing any treatment at Alpenglow because freshly exfoliated skin is more susceptible to sun damage. I also understand that to achieve results I may need several treatments. I agree to refrain from tanning beds, and understand there may be no guarantee as to the results of this treatment, due to many variables such as: age, diet, hormones, condition of skin, sun damage, smoking, climate, compliance, commitment, proper home-care product usage, etc. I understand the treatment is cosmetic and that no medical claims are expressed or implied. Lastly, I understand that I should follow my esthetician’s recommendations for prep/post-procedure to minimize side effects and maximize results.