Due to the fact that PM Lightening Therapy is a prescription strength correction cream containing
Hydroquinone and Retinoyl Palmitate, we are required to obtain the following information from all
patients prior to shipping this specific product.
If you have any questions or concerns, please contact our office at (904) 461-6060 or visit our website at
www.AvantiMedSpa.net
Name:________________________________________________DOB:___________________________
Phone Number:_______________________________E-Mail:___________________________________
Ethnic Background:
___White
___Hispanic/Latino
___African American
___Indian
___Asian
___Other, Please Specify:________________________
Skin Conditions (please check all that apply):
___Dry
___Oily
___Acne prone
___Fine lines/wrinkles
___Rosacea
___Dark spots
___Uneven texture
___Other:_________________
Please specify
Medical Problems:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Medications: (Please list)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
_______(Please initial) It is not approved by the FDA to use products containing Hydroquinone or and
Retinoyl Palmitate during pregnancy or while nursing. By providing my intials, I state that I am not
pregnant nor nursing.
_______(Please initial) I understand and consent that Avanti Medical Spa is not responsible for any
current or future adverse effects related to the topical use of Retinoyl and/or Hydroquinone.