Skin Evaluation
Questionnaire
Consultation Date:
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Birth Date
Please select a month
January
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Month
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Day
Please select a year
2024
2023
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Year
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Reason for your consultation?
*
How would you describe your skin type?
*
Dry
Combination
Oily
Normal
What are you skin goals?
*
Do you have any of the following health conditions, past or present?
*
High Blood Pressure
Low Blood Pressure
Spinal Injury
Diabetes
Heart Problems
Heart Problems
Eczema
Psoriasis
Skin Disease/Lesions
Sunburn
Hormone Imbalance
Cold Sores
HIV/AIDS
Herpes
Hepatisis B/C
Lupus
Claustrophobia
None of these apply
Other
What are your concerns with your skin?
*
Dark Circles
Roscea
Fine Lines
Uneven Skintone
Hyperpigmentation
Ingrown Hairs
Acne/Breakouts
Excessive Oil build up
Sun Damage
Lack of skincare routine
Wrinkles
Sensivitity
Redness
Dehydration/Dry
Scarring
None of these apply
Other
What Challenges would you like to improve?
*
Have you ever had a bad reaction to any skin care treatment or product?
*
Yes
No
If yes, please explain?
Is this your first facial?
*
Yes
No
If no, what types of treatments have you received to address your concerns?
*
Please upload images of the current state of your skin here:
Browse Files
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(1) Forward-facing picture of face, (2) Left-facing picture of face, (3) Right-facing picture of face.
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