Informasi berikut ini dibutuhkan untuk kenyamanan anda sewaktu anda berada di Tribeca. Segala informasi akan disimpan secara rahasia.

Are you currently taking any prescription medication ? (please list)

Are you currently taking any non-prescription medication ? (please list)

Have you used / taken Retin A, Renova, Avita, Differin, Avage or Tazorac in the last 6 month ? * Note : these medication are known to cause significant heatlh risks in assocation with particular ingredients or treatment metodologies

Are you currently applying any topical medications that might affect your skin? (please list)

Have you had an allergic reaction to any skin care products or treatments in the past ? (please explain)

Are you currently pregnant or have oyu recently given birth?

Please put a “cross” mark next to any of the conditions that are currently applicable, and provide extended ifnirmation if necessary. Note: each condition indicated might have an effect on how we (or if we are be able to ) perform your particular treatment.

Please provide additional information in the space provided.