971.409.3740

7114 N Mohawk Ave
Portland OR 97203

Hours
By Appointment Only

Sunday & Monday
Closed

Tuesday to Friday
11:30am to 7:30pm

Saturday
10:00am to 5:00pm

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* Indicates Required Information

Facial Form

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Your Email:

Password:

First Name *

Last Name *

Date of Birth *

Have you ever had a facial treatment before? *Yes
No

When and what type of facial treatment have you had? *

Do you consider your skin to be: *Dry
Oily
Normal
Combination

Skin Conditions

Please check any skin conditions you currently have or have had in the past.Hyperpigmentation (darkening of the skin)
Hypopigmentation (lightening of the skin)
Rosacea
Acne
Black heads (Comedone)
White heads (Milia)
Any other Skin Conditions

You checked Other Skin Condition, please describe: *

Have you ever taken Acutane or other acne medications? *Yes
No

Which acne medication and when? *

Have you ever received any recent services such as microdermabrasion, chemical peels or laser resurfacing? *Yes
No

Which treatment(s) and how long ago? *

Recent surgery, including plastic surgery? *Yes
No

Please describe the nature of your recent surgery: *

Do you have any piercings, tattoos, or permanent cosmetics? *Yes
No

Where on your body? *

Have you been exposed to the sun or used a tanning bed in the last 48 hours? *Yes
No

Frequency of exposure to the sun or use of a tanning bed: *Infrequently
Moderately
Frequently

Have you ever had any of the following adverse reactions after using any skin care product? (Check any that apply.)Breakout
Irritation
Peeling
Rash
Sun sensitivity

Please describe: *

Disclosure/Consent Statement

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I received here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

By clicking here I indicate my understanding and agreement to the Disclosure/Consent Statement above. *

Signature by typing name: *

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971.409.3740

Hours By Appointment Only

« Back to Forms

Facial Form

Hours
By Appointment Only