Treatment Consultation Please enable JavaScript in your browser to complete this form.12Important3Recent skin care4About your skin5ConsentYour personal detailsNameDate of BirthGenderBusiness nameAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhoneEmailNextImportantPlease complete the following questionsAre you currently using or have you used Roaccutane in the last six months?Yes NoAre you pregnant or nursing/lactating?Yes NoDo you have a cold sore today (herpetic breakout)?Yes NoDo you have any skin allergies?Yes NoPlease detailDo you have a skin infection would in the treatment area?Yes NoPreviousNextWithin the last 14 days, have you...Have you had a chemical peel within the last 14 days?Yes NoHave you had laser hair removal within the last 14 days?Yes NoHave you had a photofacial treatment within the last 14 days?Yes NoHave you had radio frequency skin tightening treatment within the last 14 days?Yes NoHave you had microdermabrasion within the last 14 days?Yes NoWithin the last 7 days, have you...Have you had waxing, threading, or any other form of hair removal in the last 7 days?Yes NoHave you had Botox in the last 7 days?Yes NoHave you had and dermal filler injections in the last 7 days?Yes NoWithin the past 3 weeks, have you...Have you been exposed to the sun in the last 3 weeks?Yes NoHave you used a tanning bed in the last 3 weeks?Yes NoNextTell Alison more about youAre you currently using any sunless tanning products?Yes NoAre you using prescription or non-prescription retinoids?Yes NoE.g. retinol, Retin-A, TazoracAre you using AHA/BHA skin care products?Yes NoAre you using any prescription topical medications at the time?Yes NoPlease detailDo you wear contact lenses?Yes NoDo you have permanent make up?Yes NoDo you participate in aerobic physical activity?Yes NoHave you ever had a cold sore?Yes NoHave you ever used any skin care products that have caused an adverse reaction?Yes NoPlease detailWhat is the ethnic background of your parents?NextWhat are the skin concerns that you would like us to help you with? Please detailI consent to this data being collected and in the event of an adverse reaction, I consent to the clinic passing this information to AlumierMD for further advice. *Yes, I consentPatient signaturePlease type full nameDateUpload a photo of your skin (optional) Click or drag a file to this area to upload. Anything else you would like to add?MessageSubmit
