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Nakai Skincare & Cosmetics

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1. Is this your first facial

No

Yes

2. Are you presently under a physician’s care for any current skin conditions or problems

No

Yes

3. Are you pregnant?

No

Yes

4. Are you taking birth control pills?

No

Yes

Date of Birth

5. Are you presently using (used in the past) Azlex, Differin, Renova, Retin-A, Tarazac, Glycolic or Alpha Hydroxy Acids?

No

Yes

Please specify anything we should know about

Initials

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I declare that the info I’ve provided is accurate & complete

I understand that the services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

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