Consultation

Skin care is personal. To ensure that you receive the right products specific to your needs please fill out this form below to get started on your new skincare journey.

Consultation Form

Your information will always be private and will be used only for your product recommendations.

Birthday

Phone

Skincare goals?

Do you wax your face on a regular basis?

Yes

No

Sometimes

Does your job and/or lifestule require that you work/play outdoors?

Yes

No

Sometimes

Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?

Yes

No

Are you using Retin-A?

Yes

No

Are you using Benzoyl Peroxide?

Yes

No

Female clients only:

Pregnant or trying to become pregnant

Breastfeeding

Using contraception

Not Applicable

Tell me about any allergies or sensitiveness you have:

Tell me about any health issues you have:

Tell me about any medications you take:

How often do you wear make up?

I don't

1 - 2 days a week

3 - 5 days a week

Every day

What skincare brands are you using now?

Where do you fall on the Fitzpatrick Skin Type

I - Pale white skin - always burns does not tan

II - Fair skin - Burns easily, tans poorly

III - Darker white skin - Tans after initial burn

IV - Light brown skin - Burns minimally, tans easily

V - Brown Skin - Rarely burns, tans darkly easily

VI - Dark Brown or Black skin - Never burns, always tans darkly

Starting budget for new skincare regimen

$20 - $40

$40 - $80

$80 - $120

Open budget

Desired skincare regimen.

Minimal - 3 Products

Give me the basics - 5 -6 Steps

Want it all - 6 products or more

Any additional comments, questions or concerns?

Parent Information for 18 and under

I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments or products received. The treatments or products I receive are voluntary and I release the company and/or skin care professional from liability.

Yes

No

Thanks for submitting!