Name *

First Name

Last Name

Phone *

(###)

###

####

Can we text you? *

Yes

No

Are you pregnant or breastfeeding? *

Yes

No

Have you recently had permanent makeup applied? *

Yes

No

Have you recently had facial waxing? *

Please discontinue the use of any hair removal products/treatments 5 days before and after this peel.

Yes

No

Are you currently using any prescription-strength topical Retinoids like Trentinoin or Retin-A? *

Please consult your dermatologist before discontinuing use.

Yes

No

Are you currently using Accutane? *

Yes

No

Have you had a chemical peel in the last 14 days? *

Yes

No

Have you recently had laser skin resurfacing? *

Yes

No

Are you currently taking any medications? *

Yes

No