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PrimeCare of Michigan
MM slash DD slash YYYY
Assigned Sex at Birth
How did you hear about us?
Who referred you?
Have you seen a dermatologist in the past year?
What is your dermatologist's name and contact information?
Have you had recent surgery or plastic surgery?
Please explain what surgery you had performed?
Have you ever had any of the following?
Skin disease/ lesions
High blood pressure
Phlebitis, Blood clots, Poor circulation
Neck or Spinal Injury
Any active infection
Head or neck pain
Please specify other conditions
Do you have any allergies to the following? (select none if you do not)
Please list other allergies
Please list any medications or supplements you are taking:
Do you (check any that apply)?
Use any recreational drugs
Consume water regularly
Follow a restricted diet
Have a pacemaker
Have any metal implants
Wear contact lenses or glasses
Frequent tanning booths
Have you experienced clausterphobia?
Are you pregnant or breastfeeding?
Are you taking birth control or hormone replacement?
Have you had a facial treatment before?
When was your last treatment?
Are you currently using any products that contain or are you taking any of the following?
Prescribed topical cream
Retinol/Vitamin A derivative products
Products containing Hydroquinone or Alpha Hydroxy
AHA’s (Glycolic Acid, Lactic Acid)
BHA (Salicylic acid)
Have you received any of these skin care treatments?
Laser Hair Removal
How long ago did you perform the above checked item?
Within the past 7-10 days
Within the past month
Within the past 2-3 months
Have you ever had an adverse reaction after using any skin care product?
What was your reaction? Check all that apply
Which product or brands cause the reaction?
Have you had botox or injectibles?
Date of last treatment for botox or injectible:
MM slash DD slash YYYY
What do you consider your skin type?
Normal (no blemishes, fine pores, smooth texture)
Oily (enlarged pores, excess oil)
Acne (cystic or nodule)
Dry (dull, visible lines/ wrinkles, feels tight)
Aging (dry, very visible deep lines/ wrinkles)
Combination (oily and dry patches, oily t-zone, hormonal acne)
Sensitive (reactive to fragrance, often irritated)
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin)
Do you have frequent breakouts?
What skin care products do you currently use?
Exfoliator or scrub
What is your daily skin care regimen?
Do you use sunscren?
What are your specific concerns at this time regarding your skin?
What is your skin care goal?
Indicate what services or areas you are interested in (check all that apply):
Minimize/ Remove Sun Spots
General skin care
I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.
I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.
I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.
I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjust
I understand that I or the esthetician may terminate the session at any
I have been given a chance to ask questions about the session
and my questions have been answered.
I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.
I, therefore, release PrimeCare Spa and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.