Skin Care Services
Radio Frequency Body Contouring And Cellulite Treatment
Copyright 2013 Orsi Skin Care Tel : 646-620-9669 or 702-803-6205 2700 E. Sunset Rd. Suite 33 Las Vegas, Nevada 89120
Please complete the intake, before your treatment so we can spend more time with your treatment.
Date Of Birth
What would you like to achive from your treatment today?
What areas of concern do you have regarding your skin?
Sun Spot/ liver spot/ brown spot
Uneven skin tone
Have you ever had an allergic reaction of the following?
Any other allergies not listed above?
Have you ever have chemical peels, laser or microdermabrasion?
In the last month?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A deriactive products?
If yes please explain
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 receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
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