Active acne or lesion? *

Yes

No

Open lesion or cold sore on the area being treated? *

Yes

No

Have you have direct exposure to sun in the last week? *

Yes

No

Skin conditions such as eczema, dermatitis, or rashes? *

Yes

No

An autoimmune disease such as Lupus? *

Yes

No

A viral concern such as HIV or hepatitis?

Yes

No

Are you Pregnant or breastfeeding? *

Yes

No

Do you have a neurological disorder such as epilepsy or claustrophobia? *

Yes

No

Have you used Accutane in the last year? *

Yes

No

Have you used any topical exfoliants like retinols or glycolic acid in the last week? *

Yes

No

Are you currently taking any antibiotics? *

Yes

No

Have you had aesthetic injectables or laser treatments in the last two weeks? *

Yes

No

I acknowledge the following: *

• Photos will be taken before the treatment for purposes of medical documentation only to be recorded on my Skin by Sylvie, Inc account. These photos will NOT be used for education, promotion or advertising purposes, without my consent. • By typing my name below, I acknowledge that I have accurately answered the questionnaire and give my consent for treatment. This consent form Is valid for all future Skin by Sylvie custom facial treatments. I will alert the staff if there are any future changes to my medical history.

I acknowledge the above information

Name *

First Name

Last Name