Return to Radiance Intake

Aloha & congratulations on taking this step towards achieving your optimal skin health! Our skin is constantly giving us clues, but are we listening? This is why becoming a detective of your own health is essential. It will give you a clearer understanding in order to address the root cause that will lead you to permanent changes that you want.

Please fill out the form below prior to your appointment or your complimentary 30 minute Return to Radiance call. Looking forward to working with you to achieve your skin goals!

"Radiant skin from within!"

In health and beauty,

Leilani Mayer, M.S., L.E.
Name *
INSTAGRAM/FACEBOOK
IG: @leilanimalieaestheticsllc
Email*
example@example.com
Phone Number

Area CodePhone Number
HOW WOULD YOU LIKE TO BE CONTACTED?*

EMAILSOCIAL MEDIA MESSAGE/DMZOOM CALLPHONETEXT
IS YOUR SKIN

DRYOILYCOMBINATIONSENSITIVEACNEIC
DO YOU HAVE (CHOOSE ALL THAT APPLY)*

SUN DAMAGEAGE SPOTSDISCOLORATION IN SKIN TONENONE
Identify the zone number(s) above*

Large brown spotsMultiple spots that resemble freckles in zone 1 & 2All of the aboveNone
DO YOU HAVE/EXPERIENCE ACNE BREAKOUTS?*

YesNo
Are you currently:*

PregnantNursingPerimenopausalNone of the aboveDoes not apply (male clients)Currently taking birth control
Identify the zone you experience breakouts*

Zone 1,2 and or 4Zone 8,9 and or 10
DO YOU HAVE LARGE PORES*

YESNO
DO YOU HAVE (CHECK ALL THAT APPLY)*

PUFFINESS UNDER EYESDARK CIRCLESHYPERPIGMENTATION/MELASMA/SKIN DISCOLORATIONFINE LINES/WRINKLES
IS YOUR SKIN DULL*

YESNO
WHICH SKINCARE PRODUCTS ARE YOU CURRENTLY USING?*

CLEANSEREXFOLIANTMASKSERUMSMOISTRUIZERSPF SUNSCREEN
PLEASE DESCRIBE YOUR DAILY SKIN CARE PRODUCTS/ ROUTINE*
ARE YOU CURRENTLY TAKING ANY MEDICATIONS? PLEASE LIST:*
HAVE YOU TAKEN ANTIVIRAL MEDICATIONS OR ANTIBIOTICS IN THE PAST?*

YesNo
WHAT ARE YOUR TOP 3 BIGGEST SKIN CONCERNS?*
WHAT ARE YOUR SKIN/HEALTH GOALS 3 MONTHS FROM TODAY?*
ARE YOU INTERESTED IN ANY OF THE FOLLOWING?

1-1 SKIN WELLNESS COACHING (ONLINE/IN PERSON WORKSHOPS FOR YOURSELF OR TEENAGER)BEAUTY BUSINESS ACADEMY (BRAND AFFILIATE PROGRAM)LONGER, FULLER LASHES + BROWS
Type a question or anything else you want me to know about your skin/health
Signature*
Date*

MonthDayYear
Date
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