Help us help you get the right products
Do you wax your face on a regular basis?
Does your job and/or lifestule require that you work/play outdoors?
What are you using now for skin care? Skincare goals?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
Are you using Retin-A?
Are you using Benzoyl Peroxide?
Female clients only:
Pregnant or trying to become pregnant
Using oral contraception
In or do for your menstrual period
Tell me about any allergies or sensitiveness you have:
Tell me about any health issues you have:
Any additional comments, questions or concerns?
Tell me about any medications you take:
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.
Combination (Dry & Oily)
How often do you wear make up?
1 - 2 days a week
3 - 5 days a week
Personal skin care products used:
Have you ever experienced a reaction to the following?
Food or Fruit
Alpha Hydroxy Acids
Thanks for submitting!