Facial Health Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Social Media Handle ..
Health Questionnaire
Please answer truthfully to your best abilility.
Within the last year have you been under the care of a dermatologist or physicians care for any skincare procedures ?If yes, please explain
Do you currently have any health concerns? If yes explain, otherwise state "N/A"
Do you have any allergies?
Please list any medications/supplements/vitamins you are currently taking
Do you smoke?
Yes
No
Do you exercise regulary?
Yes
No
Do you follow a restricted diet?
Yes
No
Type a question
Yes
No
Do you drink caffeine?
Yes
No
Do you sunbathe or use tanning beds?
Yes
No
On a scale of 1-5 , 5 being the highest what would you rate your regular stress levels?
Do you have any specific skincare concerns/ challenges youd like to focus on?
What is your skincare goals?
Select products you use on a normal basic
Cleanser
Toner
Moisturizer
Mask
Exfoliants
Eye Products
Body Scrubs
Oils
Hair Remover Products
Self Tanner
Have you ever had any chemical peels, microdermabrasions, or any resurfacing treatments?
Do you use any prescribed skincare products?
Have you experienced any of the following
Flakiness
Tightness
Dryness
Excess Oil
Do you use SPF?
Do you experience any stinging or burning of the skin?
Are you prone to skin redness?
Yes
No
Are you currently taking any oral contraception? If so please name below
Are you currently pregnant or in the process of becoming pregnant?
Are you currently due for your mentrual cycle?
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BeResilient Beauty Release of Liability
I have given all correct and truthful responses to my knowledge, and I have not withheld any information that may be relevant to my treatments. I acknowledge beresilient beauty and its affiliates are in no way responsible for any skin reactions or damages that may occur.
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Last Name
Signature
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