Complimentary Skincare Consult Form
Please fill out the questionnaire and if we believe we can help you reach your skin goals, one of our aestheticians will send personalized skincare product recommendations and lifestyle tips to you within 3-5 business days!
Full Name:
*
Date of Birth:
*
Phone Number
*
Email:
*
How did you hear about us?
*
Please Select
Instagram
Facebook
Google
Friend
Yelp
Other
What are you interested in?
Acne Treatment
Melasma Management
Rosacea Management
Age Management
Other
Do you have any allergies?
Which concerns apply to your skin? Please check all that apply:
Uneven Skin Tone
Acne
Excessive Oiliness
Fine Lines / Wrinkles
Skin Laxity
Brown Spots / Hyperpigmentation
Large Pores
Bumps Under Skin
Dryness
Dehydration
Whiteheads
Blackheads
Scarring
Redness
Sensitivity
Other
Are you currently seeing a Dermatologist or using any topical medications? If so, please list all medications and how long you have been using them.
Are you taking any internally prescription medications related to your skin, or that we should know about?
Do you consume dairy, gluten, soy or processed sugar? How often? Can you describe your typical day to day nutrition?
Daily caffeinated beverages intake?
Please Select
0
1-2
3-4
5-6
7+
How would you describe your stress level?
Please Select
Low
Moderate
High
Extremely High
Do you vape, smoke cigarettes or marijuana?
What are you main skin care concerns and goals?
If your skin gets oily, how many hours after you wash do you see oil?
Please Select
1-2
3-4
5-6
7-8
9-10
I never see oil
Where do you get oily?
Please Select
All Over
T-zone
Forehead
Nose
Chin
Cheeks
Does your skin feel dry and oily at the same time?
Please Select
Yes
No
Do you have flaky skin?
Please Select
Yes
No
Do you ever pick, poke, pop, or scratch at breakouts?
Please Select
Yes
No
Do you have a tendency to flush or blush easily?
Please Select
Yes
No
Where you a sunbather? How much sun exposure do you currently get?
How often do you wear SPF? Do you reapply every 2 hours?
What products do you currently use in the morning? Please list each product with it's brand name.
What products do you currently use at night? Please list each product with it's brand name.
Do you use any other products weekly or monthly? (Exfoliants, masks, treatments, etc) Please list brand name.
Do you wear makeup? If so, please list your foundation, powders and concealer.
How do you remove your makeup?
Do you work out? If so, what time of day?
How many minutes after your workout do you wash?
Are you pregnant, trying to become pregnant or nursing?
Have you ever been diagnosed with skin cancer?
Is there anything else we should know about your skin?
Current photos of your skin (Makeup-free!)
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Right side of the face
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Straight Forward
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Date
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