Vi Aesthetics
Date
/
Month
/
Day
Year
Date
First Name
Last Name
Email
Patient email on file
Age
DOB
Phone Number
Email Address
Patient email on file
Circle all skin concern(s) that you are seeking improvement upon.
Type a question
PIGMENT
AGING
ACNE
ROSACEA
Other
Are you pregnant or breastfeeding? If yes, you are contraindicated for a chemical peel.
Do you have permanent makeup?
Yes
No
Do you wear contacts?
Yes
No
Have you recently had facial or body waxing or used at home depilatories?
Yes
No
Do you currently have sunburn or wind burned skin
Yes
No
Do you have extended outdoor plans in the next 7 days?
Yes
No
Do you plan to participate in vigorous exercise in the next 72 hours?
Yes
No
Have you had any active skin care treatments in the past 21 days?
Yes
No
If yes, how long ago?
List all topical products applied in the last 7 days
List all prescription medications currently taken and in the past two weeks.
Have you recently undergone any surgery or laser treatments in the area to be treated?
Yes
No
If yes, provide details
Do you receive injectables?
Yes
No
Do you develop cold sores?
Yes
No
Do you have any known allergies or sensitivities? (Pleaselist)
Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, etc
How would you describe your skin?
Sensitive
Normal
Resilient
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