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Facials & Skin Treatments
Waxing
Home
About
Services
Facials & Skin Treatments
Waxing
Payment Plans
Contact
FAQ
dr. schrammek green peel intake form
Name
*
First Name
Last Name
Do you suffer from any allergies? If so please list. Put NA if you have no allergies.
*
Do you suffer from herpes simplex? (Fever blisters) Please answer Y or N
*
Do you suffer from any diseases? Please answer Y or N
*
Are you currently under the care of a dermatologist? Y or N
*
Are you currently taking medications?
*
Yes
No
Do you take Cortisone in tablet or salve form?
*
Yes
No
Do you take Vitamin A acid in salve or tablet form?
*
Yes
No
Have you had any of the following treatments during the past 6 months? Please check all that apply
*
Fruit acid
Laser treatment
Anti-wrinkle injection
Plastic surgery procedures
NA
Are you currently or possibly pregnant?
*
Yes
No
By checking "I Agree" below, you are acknowledging that you have been thoroughly informed about the procedure (Or I will be) informed about the peeling treatment and I am aware that I am not allowed to rub or peel off the skin's layers that will loosen and peelautomatically as a result of the treatment.
*
I agree
By selecting "Yes", you are agreeing and committing to your prescribed Green Peel Post Treatment Care.
*
Yes
No
By selecting "Yes", you are acknowledging that you have (Or will be) receiving your products for the use after your treatment at home.
*
Yes
No
Thank you!
