This Skin Care Questionnaire will allow us to have an understanding of what your skin type is, and allow us to determine the best possible protocol to get your skin back in order!
Name: First Name* Last Name* Age:Age DOB: Date* Sex: Male Female* Gender: Male Female Others Race: Please Select White American Indian Alaska Native Asian Black Pacific Islander Native Hawaiian Home Address: Street Address City State Zip Phone Number:Phone Number*Email: Email* Allergies: Sulphur Aspirin Shell Fish Nuts Other
Are you currently under a lot of stress? Yes No WOMEN: Do you use birth control pills, shots or an IUD? Yes No If so, What Brand? MEN: Do you have shaving Irritation? Yes No What type of razor do you use? Type a label