iS Consultation Card

First Name

Last Name

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Phone - Day

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Please list if you have or had any of the following: Cancer, Herpes, HIV/AIDS, Seizure Disorder, Thyroid issues, Diabetes, Arthritis, Keloid Scarring, Hepatitis, Blood Clotting issues, High Blood Pressure, Frequent Sores, Skin Disease, Hormone Imbalance.

Please list any other medical conditions not listed.

Please list any allergies.

Please list any medications you are currently taking including vitamins and dietary supplements

Within the last year, have you had any health problems that have affected or could affect your skin?

Do you wear contact lenses?

Have you experienced claustrophobia?

What are your specific concerns/challenges with your skin?

What skin care products are you currently using?

Are you currently using any products that contain the following?

Glycolic Acid
Hydroxy Acids (AHAs, BHAs)
Lactic Acid
Vitamin A derivatives (ie. Retinol)

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Please sign and date.

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By Filling this information out to us, you will be entered to win a $50 Bella Salon & Spa Gift Certificate.

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