Skin Care Consultation
Need some help with your skin! We are here to help. Please be as detailed as possible so we can give you the best recommendations possible!
Email address *
Name *
Age *
Phone # - If you would like to receive a follow up call
Have you had a facial treatment before? *
If Yes, when was your last treatment?
What was the focus of that treatment?
I would describe my skin as *
How long after you cleanse your skin do you notice oil? *
Which of the following best describes your skin? *
On a scale of 1-10 how would you rate the overall health and appearance of your skin? *
Needs a Complete Overhaul!
Perfect!
What does a "10" look like to you? *
What would you like your skin to be on a scale of 1-10? *
Needs a Complete Overhaul
Perfect
By When? *
Do you have any special skin problems or concerns?
Do you use Retin-A, Renova, Acutane, Adapalene Hydroxy Acid or Retinol/vitamin A derivative products? *
If Yes, please list
Please list any acne medication (internal or topical)
What areas of concern do you have regarding your skin? *
Required
What areas of concerns for you Eyes? *
Required
What are areas of concern for your Lips?
Current Skin Care Routine
Please answer the following as detailed as possible (brand name, type, etc)
Cleanser
Toner
Serum
Scrub/Exfoliant
Day Moisturizer
SPF
Night Cream
Eye cream
Makeup
Other
On a scale of 1 to 10 how well do you think your skin care products are helping with the concerns you listed? *
Not at all
Completely
What results would you like your products to give you that they are not giving you now?
Do you have any allergies? *
If Yes, to what ingredients?
Have you ever had a reaction to a skin care product? *
If yes, or maybe, please explain
Are you pregnant? *
How would you like us to follow up with you? *
Required
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