Skin Survey | Chi Browtique

Confidential Skin Health Survey

First name

Last name

Phone

Email

Is this your first facial?

yes

no

What is the reason for your visit today?

yes

no

Any special preference?

yes

no

Are you currently under a physicians care for skin condition or other problem?

yes

no

Are you pregnant?

yes

no

Are you on birth control?

yes

no

Hormone Replacement?

yes

no

Do you wear contact lenses?

yes

no

Do often experience stress?

yes

no

Have you had skin cancer?

yes

no

Do you have or have you ever had any back or neck injuries?

yes

no

Multi choice

Option 1

Option 2

Are you now or have you used Accutane?

yes

no

Do you have acne?

yes

no

Do you have any food drugs or cosmetic allergies?

yes

no

Are you currently taking oral or topical medications?

II give permission for Chibrowtique to perform facial procedures, I certify that i am 18 years of age or older .or that you have a parent consent. I confirm that all of the questions are answered accurately.

Signature

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