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Robyn Ryan Consultation Information
Thank you for choosing Carribean Beauty Secrets for your skin care needs.
Please take a moment to fill out this form for the most effectiveness of your skincare treatments.
Each section asks questions that provide information about your skin's conditions and necessary to help determine what treatments and products to offer.
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Email
*
Your email
Name
*
Your answer
Email
Your answer
Telephone
Your answer
What would you like to achieve from your treatment today?
Your answer
Have you ever had a facial, or body treatment before? If so, when?
Your answer
Which of the following best describes your skin type?
Porcelain - Ivory - Light.
Medium - beige
Brown / Black
Other:
Do you have any special skin problems or concerns pertaining to your face or body?
Your answer
Have you ever had chemical peels, laser or microdermabrasion? No / Yes - In the last month?
Your answer
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? No / Yes describe:
Your answer
Have you used any of these products in the last 3 months?
Soap
Toner
Eye
Cleanser
Day Moisturizer
Shower Gels
Body Lotions
Sunscreen SPF
Night Moisturizer/Cream
Makeup Products
Other:
Have you used an acne medication?
when?
Which drug?
Your answer
Please check areas of concerns
Acne and / or Blemish Control
Pigmentation, Redness / Discolouration
Premature Aging
Sun Damage
Stress Reduction & Relaxation Benefits
Pore size and Surface Conditions
Other:
Allergy’s
If Yes Explain
Your answer
Recent Surgeries
If Yes, explain.
Your answer
Medications: Please check all that apply
Oral Contraceptive
Harmone Replacement
Antibiotic
Steroids
Accutane
Retin A
Other
Other:
Future Appointments/Contact:
May I call you at your home, work or cell phone number to confirm future appointments?
Yes
No
Other:
Clear selection
May I contact you via mail/email about future promotions and news?
Yes
No
Other:
Clear selection
I understand, have read and completed this questionnaire truthfully.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Copyright Issues
Caribbean Secrets Showroom & Studio
1225 E River Drive #216
Davenport, Ia. 52803
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No
Other:
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Signature
Enter Full Name
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