Anti-Aging Treatment Form Please fill out the form as completely as possible. Name(Required) First Last Date of Birth(Required) Cell Phone(Required)Email(Required) Preferred Communication Methods Phone Call Text Email What are your top 3 skin goals right now?(Required)What concerns are you hoping to improve? (check all that apply)(Required) Acne/Breakouts Pigmentation/Sun Damage Fine Lines/Wrinkles Texture/Scarring Redness/Sensitivity Aging/Firmness Dryness/Dehydration If you could improve ONE thing first what would it be?(Required)Have you had professional treatments before? If yes which ones and when?List what you currently use (if unsure, write not sure)CleanserExfoliantSerumsMoisturizerSPFRetinols/Tretinoin (if yes, how often?Are you open to at home skin care product recommendations?(Required) Yes No Water intake, how many ounces?(Required)Stress Level? (Low, Moderate, or High)(Required)Diet? (Balanced, High Sugar, or Inconsistent)(Required)Sleep? (Great, Fair, Poor, or Inconsistent)(Required)Medical and Contraindications:(Required) Accutane (current/past 12 months) Retinol/Tretinoin Autoimmune conditions Diabetes Hormone therapy Pregnancy/Breastfeeding Cold sores/Herpes simplex Allergies (please list) Medications (please list) Please list your allergies below(Required)Please list your Medications below(Required)What is your ideal comfort zone for cost of treatment recommendations per treatment? $120 $175 $195 Open to recommendations Which do you prefer? A one time treatment A series for visible results A long term skin plan to include maintenance treatments Anything else you want me to know?How did you hear about Clear Solutions Acne & Skin Care Clinic?
