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Facial Skin Types: (required)
 Normal Oily Dry Combination Sensitive Acne Mature

Present Skin concerns:
 Hyper/Pigmentation Dhydration Rosacia Blackheads
 Whiteheads Melasma (Dark Patches) Dilated Pores Sun Damage
 Blemishes Acne Scars Enlarged Pores

Prescribed Medications:
 Antibiotics Accutane RetinA
 Cortisone Cleosin E Mycint

Have you ever used:
 Benzyl/Peroxide Sulfa Salicylic/Glycolic Acid Bleach None

Allergies?

Do any of the following apply to you?
 Smoke Exercise Wear Contact Lenses
 Eat Spicy Foods Burn Easily Tan Easily

Have you ever been diagnosed with any of the following?
 Anxiety Depression Migraines Asthma
 Sinus Problems High/Low Blood Pressure Cancer
 Diabetes Thyroid Epilepsy Heart Problems
 Hemophilia Hepatitis Herpes HIV Other

Emergency Contact (name, phone & relationship): (required)

Notes:

I hereby give my consent and authorization voluntarily and release Picasso Day Spa & Salon and the aesthetician assigned to me from any claims; implied or stated that I have or may have in the future in connection with this treatment, regarless of results. By checking the box below I am stating I fully understand all of the above and that the treatments process has been satisfactorily explained to me.

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