Dermalogica

Name: *

I confirm(to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. *

Yes

If yes, please specify:

Age *

Phone *

Please specify if any of the following apply to you: *

pregnant

trying to become pregnant

lactating

menstruating

pre-menstrual

Not applicable

Within the last year, have you had any health problems that have affected or could affect your skin? *

Do you have sinus problems? *

Yes

Do you wear contact lenses? *

Yes

Do you have any allergies? *

Yes

Have you been waxed within the last 72 hours? *

Yes

What are your specific concerns/challenges with your skin? *

Are you currently using any products that contain the following ingredients? *

Glycolic Acid

Lactic Acid

any exfoliating scrubs

Hydroxy Acids(AHAs,BHAs)

Vitamin A derivatives(i.e.,Retinol)

None

Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months? *

Yes

Have you ever experienced claustrophobia? *

Yes

Email: *

Do you have metal implants, a pacemaker or body piercings? *

Yes

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months? *

Yes

What skin care products are you currently using? Check all that apply. *

soap

cleanser

toner

moisturizer

masque

exfoliant

eye products

other

none

List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, etc. that you take regularly. *

Spa Arilena

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Let's get personal!

Please answer these questions to help us provide the best service for your skin.

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Dermalogica

104 N Fordham Ave, Aurora, IL 60506, USA

+1(630)251-7666

jeannacorral@yahoo.com

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