Welcome to Joshua Bay Aesthetics

Name:

Address:

Phone Number:

E-mail Address:

Date of Birth:

Please list any minimally invasive cosmetic procedures or chemical peels you have had:

Have you ever had problems with any procedure listed above? Yes No

If yes, please explain:

Please list all medications, homeopathic supplements and vitamins you are currently taking:

Please list any medical history or medical diagnosis that you are being treated for:

Please list any past surgical history:

Please list any significant family medical history:

Do you have any allergies to medications? Yes No

If yes, please explain:

Are you pregnant, trying to get pregnant or breast feeding? Yes No

Are you prone to having cold sores? Yes No

Please list the cosmetic services that interest you:

Are you currently using Retin-A? Yes No

Do you regularly see an aesthetician for facial waxing procedures? Yes No

Are you currently using hydroquinone? Yes No

Do you use a facial toner after cleansing? Yes No

Do you have an allergy to latex? Yes No

Please list the products you are currently using in your skincare regime:

Please check all that apply:

What concerns you most about the overall appearance of your skin?

Fine lines and wrinkles	Frequent Breakouts
Brown spots, sun damage or melasma	Redness, irritation
Broken capillaries, spider veins	Large, visible pores
Excessive hair	Loose skin / Cellulite
Ingrown hairs/Follicular inflammation

How would you describe your skin?

Oily	Dry	Combination
Sensitive to products	Itchy/Flaky during winter	Excessive buildup during summer

Regarding the skin around your eyes, do any of the following descriptions concern you?

Crow's feet

Fine lines and wrinkles

Dark circles

The answers I have provided are true and correct to the best of my knowledge.