Facial Consent Form
Email address *
Name *
Your answer
Email *
Your answer
Address *
Your answer
Phone number
Your answer
Have you had a facial before? *
If so when?
Your answer
Check which skin care products you are currently using?
What concerns you the most about your skin?
Are you taking medications? *
Have you had surgery in the last year? *
Are you pregnant *
Please check if you are have or had any of the following
Have you had a fever blister in the last 2 weeks? *
Do you wear contacts? *
Have you ever used AHA's or Retinol products? *
Are you using or ever have used any of these products?
How long if you checked any above?
Your answer
Have you ever had a reaction to any of the above listed products or any others?
Your answer
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