Treat'd by Wink'd

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Treat'd by Wink'd

This form will utilize in the first step of a Treat'd Session or Facial Therapy.

Email *

Name and Age *

How do you currently care for your skin? *

Do you have any specific skin concerns & goals. If there was one thing I was able to fix today, what could it be. *

In order to best understand you, your skin and the history behind both; I need to know as much as possible. Please share with me any and all information you can regarding prior treatments given, medications taken, doctors visited, diagnosed or undiagnosed issues and concerns. *

In some cases, our diets can reflect in our skin's reactions. In your own words, please describe your daily diet/eating habits/food aversions/allergies etc.

Are you currently experiencing cold symptoms? *

Yes

Are you currently pregnant or nursing? *

Yes

Do yo have any heart conditions? Including pace makers, etc *

Yes

Do you or anyone in your immediate family have history of skin cancer? *

Yes

Other:

Please list any anxieties, details or triggers you want me to know about. This can be as general or specific as you'd like to share.

Any thing else you'd like me to know

Submit

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