Face Sculpting Questionnaire We can’t wait to have you in the studio. please fill out this questionnaire at least 48 hours before your skin consultation. CONTACT INFO Name * First Name Last Name Email * Phone * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Personal Care Doctor * Please describe any recent facial and/or medical treatments you've had and the reason for them. * Your Medical History * Have you experienced any of the following? Check all that apply. Heart conditions/pacemaker Severe Circulatory disorders/DVT Diabetes Kidney problems Swelling/Edema Haemophilia Cancer Limitation of body movements/arthritis Pregnant Epilepsy Keloid scarring Hormone imbalance Stroke Claustrophobia Hepatitis Metal plates/pins/piercings Recent Scar tissue/surgery Respiratory problems Allergies Any other medical conditions/ailments I should know about? Please be as detailed as possible. Have you received botox, filler, or PDO threads in the last 6 months? * If yes, please specify. Have you received any dental treatment in the last 6 months? * If yes, please specify. What pressure do you prefer on your face? * Firm Medium Light What pressure do you prefer on your body? * Firm Medium Light What are your hopes and expectations for your treatment? * Do you currently use any of the following? * Steroids Ultra violet exposure Retinol/Accutane Products containing fruit acids Microdermabrasion If you checked any of the above, please specify. Are you taking any other medications? * If yes, please specify. I declare that the above information I have given concerning my health is correct. * Yes, I declare. Type your name to sign: * First Name Last Name Today's Date * MM DD YYYY Thank you!
