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Oxygeneo Facial Treatment Form
Please take the time to fill out the information below.
First Name
Email
Birthday
Last Name
Phone
Address
Referred by:
Gender
Health Questionaire
Skin Disorders
Distended capillaries
Acne
Eczema
Allergies
Pregnant
Retin-A
Birth Control
Blood disorder
HIV/AIDS
Hyper/ Hypo pigmentation
Cancer
Hyper/Hypo Throid
Recent Surgeries
contact lens
Diabetic
Nervous Diseases
Cardiac disorder
Vascular disorder
None of the above
Check things you would like to improve.
Lines
Wrinkles
rough texture
Dullness
Pores
blotchiness
hyperpigmentation
Dryness
Age spots
Breakouts
Oily
Prevention
Scaring
Please disclose any other health Details
What is your primary concern?
Do you experience sensitivity or skin irritation to skin care products?
Yes
No
If yes please explain
Personal Skin Care Routine Please check (√) current products you use:
Cleanser
Make-up Remover
Toner (Astringent)
Exfoliator (facial scrub)
Mask
Moisturizer (Day Cream)
Night cream
Eye cream
Sunscreen
Do you take or use any products that contain the following; Isotretinoin, Tetracline, Retinoic Acid, AHA Glycolic Acid, Hydroquinone, Aspirin, Anticoagulant:
Have you recently had any type of chemical or glycolic peel? If glycolic, what percentage? If Chemical, Please describe:
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