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Piel by Delia
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First name
*
Last name
*
Email
*
Phone
*
Birthday
*
Month
Month
Day
Year
Do you have any specific concerns on your skin you’d like to address?
*
What products are you presently using on your face?
*
Are you currently using any of the following?
*
AZELEX
DIFFERIN
RETIN A
ACCUTANE
RENOVA
TAZARAC
GLYCOLIC/AHAs
SALICYLIC ACID
MERTOGEL
If yes to any of the above, how long?
*
Do you have any allergies to cosmetics, drugs, or food?
*
Are you taking any oral or topical medication?
*
Do you have any piercings that aren’t removable?
*
Do you wear contacts?
*
Do you smoke?
*
Do you have acne?
*
Do you experience stress often?
*
Do you experience frequent blemishes if so, how often?
*
Are you pregnant or trying to become pregnant?
*
Are you taking birth control pills or hormone replacements?
*
Have you had cancer? If so, are you in remission and for how long?
*
Check all that apply to you:
*
Asthma
Hepatitis
Metal
Bone/pins/plates
Botox
Facial fillers
Cardiac problems
Chronic headache/migraines
Herpes/fever blisters
Pacemaker
Eczema
High blood pressure
Psychological problems
Epilepsy
Hysterectomy
Immune disorders
Lupus
Pregnancy
Diabetes
Diuretic/diet pills
Cancer
Urinary/kidney problems
Sinus problems
Rosacea
Hemophilia
Bleaching creams
Blood thinners
Steroids
Wax regularly
Drink water
Tanning beds
Drinks alcohol
Exercises regularly
Claustrophobia
Are you OK with me following up days after your service through any contact information provided above?
*
Yes
No
Do you consent to having pictures/videos taken and posted on social media?
*
Yes
No
Only if I see the pictures first!
Submit
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