Monday & Tuesday 9:00am – 5:00pm
Wednesday 9:00am – 7:00pm
Thursday & Friday 9:00am – 5:00pm
Saturday & Sunday Closed
1170 Dolphin st White Rock, BC, Canada V4B 4G8
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* Please mention when and for how long in each applicable field:
Antibiotics
Accutane
Benzoyl Peroxide
Clindamycin Topical
Adapalene
Retin A Cream / Gel
Tazorac
Differin
Azelex
Sulfur
Clindamycin Oral
Androstendione
Cortisone
Minocycline
Copaxone
Testosterone
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Disufuram
Cyclosporin
Dilantin
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Thyroid Medication
Quinine
Isoniazid
Immuran
Danzol
Gonadotrophin
Steroids
Recreational Drugs
Antidepressants
Other? Please specify:
What supplements are you currently taking?*
Cleansers*
Toner*
Serums*
Moisturizers*
SPF*
Masks*
Foundation*
Blush / Bronzer*
Exfoliant (ex. Glycolic)*
Acne Medications*
When did you use each of these products?* (ie - Month/Year/How long)
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face? YesNo
If yes, describe:
Check if you are allergic to:* SulfurAspirinLatexNone
Do you smoke? YesNo
At what age did your acne start?
Do you use fabric softener or fabric softener sheets in the dryer? YesNo
Do you pick at your skin? YesNo
Do you work around chemicals, tars, oils or inks? YesNo
Are you currently under a lot of stress? YesNo
Do you swim in chlorinated pools?*
Do you regularly ingest: Salty Foods
Milk/Yogurt
Cheese
Processed Foods
Whey/Soy Protein
Peanut Butter/Peanuts
Women only: Are you on birth control pills or IUD?* YesNo
If so, which brand?
Are you taking Depo Provera shots? YesNo
Are you pregnant or nursing? YesNo
What are your skin care concerns?:* BlackheadsDehydrated SkinDry/Flaky SkinOilyWhiteheadsDark SpotsSensitive SkinNormalPimples/PustulesAge SpotsRazor BumpsDryCystsBroken CapillariesShaving IrritationOily/DryOily SkinFine Lines/WrinklesAcne RosaceaSensitiveNone
Have you done the following treatments before?* Glycolic Acid PeelsMicrodermabrasionChemical PeelsSkin Cancer RemovalPlastic SurgeryLaser Hair RemovalFacial WaxingElectrolysisOtherNone
If so, please explain:
Medical History: Check any condition you may have had in the past two years:* DiabetesHepatitisHemophiliaThyroid ProblemsHIV + or AIDSThrombosis/BloodClot/StrokeEczemaStaph Infection or MRSAMetal pins or brackets in bodyPsoriasisHormone ProblemsPacemakerPregnancyHerpes Simplex/Cold SoresHysterectomy/ovaries removedNursingHigh Blood PressurePCOSCancerAnemiaLupusNone
Are you under a Dermatologist’s Care? YesNo
What kind of work do you do?*
How did you hear about us?*
What results would you like to obtain with your skin?*
Please submit 3 photos of your skin: left side, right side and straight on. *Please take skin photos in natural light. (Facing a window is best.) **Please don't use direct sunlight or synthetic light (these create shadows).
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