Pre Appointment

This form needs to be filled out prior to your appointment. This information will be reviewed at your appointment.

Please fill out this form prior to your appointment.

Appointment Date

First name

Last name

What is your goal for to this visit?

Which conditions would you like to improve?

Acne scaring

Acne

Age Spots

Enlarged pores

Fine lines and wrinkles

Hyperpigmentation

Stretch marks

Surgical/facial scars

Other

What medications are you currently taking? (if this is not your first appointment with me and there is no change please just indicate there are no changes)

If you did not also fill out the Health History today - are there any changes in your health that I should be aware of?

If this is not your first visit, has your skin care routine changed since your last visit?

If your last facial treatment was not with me when was your last facial treatment and what was it.

I do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that, I may have additional questions or concerns regarding my treatment or suggested home product routine I will inform my skin care professional immediately.

I release and hold harmless the skin care professional Heather Craven of Skin Envee from any liability for adverse reactions that may result from this treatment.

if you are not satisfied with your service or products, please contact me within 24 hours after your appointment so that the situation may be corrected. it is my policy to provide you with the best professional service and products customized for your skin condition.

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