Electronic Facial Form - Rosewater Spa & Wellness

Name*

Phone*

Email*

Birthday*

Mailing Address*

City*

State*

Zip*

Emergency Contact*

Emergency Contact Phone Number*

What would you like to achieve with your skin treatment today?*

Have you had a facial treatment/chemical peel before?*

Yes No

Do you have any special skin problems or concerns?*

Yes No

If yes, please describe:

Are you presently under a physician's care for any skin condition or other related problems?*

Yes No

If yes, for what?

Are you currently taking any antibiotics?*

Yes No

Have you ever used Hydroquinone?*

Yes No

If yes, how long ago?

Do you currently use wax, electrolysis, or depilatories, or any form of hair removal on your face?*

Yes No

If yes, what kind?

Have you ever been diagnosed with skin cancer?*

Yes No

If yes, where?

Do you wear sunscreen on a regular basis?*

Yes No

Do you have any metal implants?*

Yes No

If yes, where?

Do you smoke regularly?*

Yes No

Do you have permanent makeup?*

Yes No

If yes, where?