INTAKE FORM

Are you currently using or taking: Accutane, Adapalene, Alustra, Avage, Avita, Differin, Isotretinoin, Renova, Retin A, Tazarac, Tazarotene, Tretin?

Yes

No

Do you have tendencies towards : ingrown hair, break outs, or bumps?

Yes

No

Do you have tendencies towards : hyperpigmentation, bruising, or scarring?

Yes

No

Do you have tendencies towards : eczema or psoriasis?

Yes

No

Are you a carrier of the herpes virus?

Yes

No

Are you currently using: alpha-hydroxy acid, glycolic acid, any scrubs or peels?

Yes

No