Skin Assessment Form Please fill out the following form for your assessment.First Name *Last Name *GenderPreferred PronounsOccupationCanadian Citizen/Permanent Resident?YesNoMB Health (6 digit #)0 / 6PHIN (9 digit #)0 / 9OtherStreet AddressCityState/ProvinceZIP / Postal CodeD.O.B.DayMonthYearPhoneWorkHomeCellMedications (including Vitamins and Supplements)?YesNoPlease specify wich medicationsList all Allergies/Reactions?YesNoPlease specifyMedical Conditions/Illness/Past Surgeries?YesNoPlease specifyDo you smoke tobacco?YesNoHow much per day?Do you consume or smoke marijuana?YesNoHow often?Are you pregnant?YesNoBreastfeeding?YesNoDo you plan on becoming pregnant within the next 6 months?YesNoHave you had Filler/Hyaluronic Acid Injections?YesNoIf Yes Last treatment date:Have you had Botox® Injections?YesNoIf Yes Last treatment date:Do you have history of Cold Sores?YesNoDo you wear contact lenses?YesNoDo you have permanent makeup?YesNoIf yes, to which areas of the face?Do you use tanning beds/booths/self-tanner?YesNoAre you currently using Retin-A®/Retinol/Tazorac®?YesNoIf yes, what strength? For how long? How frequently?Have you had any chemical peels, laser treatments or any facial procedures?YesNoIf yes, was it within the last 14 days?YesNoDo you have sensitive skin?YesNoHave you ever used any products that caused a bad reaction?YesNoIf yes, describeDescribe your skin (Check all that apply):ThickThinFirmNormalDryT-Zone/ComboOilyAcneSun-DamagedUneven/BlotchyMaturePatchy DrynessMelasmaPsoriasisWhat is your skin tone?LightMediumReddishFreckledOliveLight BrownDark BrownBlackWhat is your natural hair color?What is your ethnicity?Would you like to hear about any of our other services? (Please check all that you are interested in)Cosmetic Plastic SurgeryLaser Skin TreatmentsInjections (Botox and/or fillers)Medical Grade Skincare ProductsHow did you hear about our clinic?Magazine AdTikTokFacebookInstagramFriends/FamilyWebsiteGoogleReal Self / Rate MDOtherSpecifyThe above information is accurate to the best of my knowledge.DateDayMonthYearSignatureSend MessagePlease do not fill in this field. Get Access to Our Exclusive Monthly Specials Sign Up TodayFirst Glance Rewards® Join the First Glance Rewards Program®Collect points every time you visit. As a member, you’ll save on your favourite treatments. SubmitPlease do not fill in this field.
