Agent Rx + Skin History Form

Name:*

First Last
Mobile:*
E-mail:*
We will never sell your email to a third party.
How did you hear about Agent Rx?*
Your Skin Journey
How would you describe your skin type?*

DrySensitiveCombinationBalancedOily
Have you ever had a facial?*

YesNo
If yes, what did you enjoy most about your experience?
Which skin conditions would you like to improve?*

AcneAcne MarksDry SkinFirmnessGeneral Skin HealthLines & WrinklesOily SkinPigmentationRednessRosaceaSensitive SkinTextureOther
What areas would you like to improve?*

FaceNeckChestHands
List all topical skincare you use on a daily/weekly basis:
Your Daily Skin Care

Please list the product names and brands. This is important to identify any products that may not be a good fit for your skin.

Your Medical History
Have you experienced a reaction to a topical product?*

YesNo
If yes, please list the details:
Do you have any Food Allergies or Sensitivities?*

YesNo
If yes, please list:*
Are you taking any supplements or herbs?
Are you taking any prescription medications?
Do you have an implanted IUD?*

YesNo
If yes, list type/brand:
Are your eyes very sensitive to bright lights?*

YesNo
Do you experience claustrophobia?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Prepare for your appointment:
- You will recieve a confirmation email/text one week prior to your service. PLEASE CONFIRM your appointment through the link provided.
- Discontinue exfoliation (scrubs, peels, AHA/BHA serums) at least 3 days prior to your treatment.
- Discontinue prescription retinoids (Retin-A) 5-7 days prior to your treatment.
- Wait 1-2 weeks AFTER Botox™ or consult your injector.
- Wait 7 days -2 weeks AFTER filler or consult your injector.
- DO NOT PLAN intense workouts/sweating/sauna/spa for 24-48 hours after your facial treatment.
- If you are prone to cold sores/fever blisters, you may need a prophylactic like Valtrex prior to your facial. Consult your Doctor.
I agree to the processing and storage of personal data by Skin Clinical SF, Inc. DBA Agent Rx. I understand the information I provide is only used to correctly analyze my skin and avoid possible reactions. My information is confidential and is NOT sold to third parties.*

I agree.
Date*

MonthDayYear
Signature*
Should be Empty:

Your Skin Journey