Amanda Roithmayr –

Full Name: Amanda Roithmayr
Date of Birth: 1989-07-02
Email Address:
Emergency Contact: Sherry Roithmayr
Medical History : Other, – None
Additional Details :
Have you been under the care of a dermatologist within the past year? Yes, – For acne meds as well as skin checks once a year
Are you taking any medications or dietary supplements? Yes, – Spirinolactone and Prozac
Have you had any surgery in the last 12 months? No, –
Have you received Botox, Restylane, Collagen or any other injections in the last 6 months? No, –
Do you wear contact lenses? No, –
Is there anything that may be important for us to know?
For ladies: Are you pregnant, planning a pregnancy, breastfeeding, using birth control or menstruating? Array
For ladies: Are you taking birth control pills? No,
Body Concerns:Stress, Energy levels, –
What is your current facial care routine?

Facial concerns: Blackheads/Whiteheads, Breakouts / Acne, Sensitivity, –
What is your current body care routine?

Name : Amanda Roithmayr
Signature :

Enter Date : 2022-05-05

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