Skincare Assessment
Not sure what skincare you need? Please complete the following questionnaire so our skincare specialist can better develop a customized skincare routine for you. Once the form is completed, we will contact you to schedule a consultation. The skincare consultation fee is $50 and it's credited to your skincare products at checkout.
Which are you interested in learning about? (Check all that apply)
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Skin Care Products
In-Office Skin Treatments
Shipping Skin Care Products
We can only ship products within the United States.
Full Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Birthdate
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-
Month
-
Day
Year
Date
Preferred Shipping Address for Purchased Products
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select your skin type below. If you are unsure, choose the one that sounds most similar to you.
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I - Pale white skin; extremely sensitive skin, always burns, never tans (example: red hair with freckles)
II - White Skin; very sensitive skin, burns easily, tans minimally (example: fair skinned, fair hair, northern Asians)
III - Light brown skin; sensitive skin, sometimes burns, slowly tans to light brown (example: darker caucasians, some Asians)
IV - Moderate brown skin; mildly sensitive, burns minimally, always tans to moderate brown
V - Dark brown skin; Resistant skin, rarely burns, tans well
VI - Deeply pigmented dark brown to black skin; Very resistant skin, never burns, deeply pigmented
The following information is essential to optimize your treatment plan.
Please select your concerns from the following list. (Select all that apply)
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Fine lines
Uneven skin tone
Dehydrated skin
Oil control
Dryness
Rosacea
Texture
Sun Damage/Dark Spots
Acne
Pores
Skin Laxity
Thin neck skin
Acne scars
Are you currently pregnant, actively trying to become pregnant or nursing?
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Yes
No
Are you currently using or have you previously used medical grade skincare?
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Yes - I used medical grade skincare in the past
Yes - I am currently using medical grade skincare
No - I have never used medical grade skincare
What skincare products do you currently use? (Select all that apply)
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Cleanser
Exfoliant
Moisturizer
Eye Cream
Toner
Serum
SPF/Sunscreen
Retinol
Pigment Corrector
None of the above
Other
Please select any prescription medications you are currently taking. (Select all that apply)
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Accutane
Differen
Retin A
Renova
Tazorac
Antibiotics
None of the above
Triluma
Soolantra
Other Rosacea Product
Other
Are you allergic to any cosmetic ingredients, medications or food?
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Yes
No
Have you used retinol in the past?
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Yes
No
Have you used hydroquinone in the past?
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Yes
No
In a few words, please describe your primary concerns or goals for your skin.
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Please provide one picture of your skin or problem areas, and another full face photo. (Please upload make-up free selfies with good lighting and without a filter).
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Your Experience With Skincare
What would you consider your skincare experience level?
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Beginner: I need to learn it all
Some Experience: I know the basics
Expert: I am a skincare junkie
How long is your skincare regimen?
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Short and sweet (1-3 steps)
Advanced (4-6 steps)
I understand the skincare consultation is $50 and the fee goes toward the skincare products at checkout.
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I understand.
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