Consultation Form
Help us help you get the right products
Birthday
Phone
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
What are you using now for skin care? Skincare goals?
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
Using oral contraception
In or do for your menstrual period
Not Applicable
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.
Yes
No
Skin Characteistics:
Mature
Mild Acne
Sensitive
Moderate Acne
Flaking
Redness
Sunburns Easily
Dry
Oily
Combination (Dry & Oily)
How often do you wear make up?
I don't
1 - 2 days a week
3 - 5 days a week
Every day
Personal skin care products used:
Moisturizer
Soap
Masque
Scrub
Cleanser
Toner
Have you ever experienced a reaction to the following?
Cosmetics
Medicine
Latex
Animals
Pollen
Iodine (shellfish)
Food or Fruit
Fragrance
Sunscreen
Alpha Hydroxy Acids
Submit Answers
Thanks for submitting!
Home
My Story
Skin Belief
Let's Connect!
More