Online Dermalogica® Consultation Card
1. Have you tested positive for COVID-19, or been in contact with someone who has in the past 14 days?
2. Have you been tested for COVID-19 and are currently awaiting the test results?
3. Do you have any of the following flu like symptoms: fever, dry cough, body aches, headaches, sore throat, runny nose, shortness of breath? (Note: This refers to new or unusual symptoms not aligned with medical history. You may exclude known personal medical conditions that have the same symptoms, e.g. allergies, history of migraines.)
4. Are you or your immediate contacts in a high-risk category?
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Name
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1. Within the last year, have you had any health problems that have affected or could affect your skin?.
3. Do you wear contact lenses?
4. Do you have sinus problems?
5. Do you have any of the following?
6. Have you ever experienced claustrophobia?
7. Do you have any allergies?
9. What skin care products are you currently using?
10. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?
11. Have you been waxed within the last 72 hours?
Have you shaved within the last 24 hours?
12. Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
13. Are you currently using any products that contain the following ingredients?
14. Please specify if any of the following apply to you:
15. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?
16. Do you have active cold sores?
17. Have you received Botox or other injectable procedures within the past week?
18. Do you sunbathe or use tanning beds?
19. Do you experience redness, itching, or stinging on your skin?
Please confirm that you agree to the following: I release Dermalogica (UK) Limited and Yourtime Therapies and their respective officers, directors, agents and employees, of and from any liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel Treatment, including, but not limited to, those injuries and damages caused by breach of warranty, express or implied, excluding negligence or an act or omission that directly causes personal injury, on the part of Dermalogica and Yourtime Therapies.
I have received Post-Care instructional sheet.