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    Holistic Skin Center

    602 W Indian River Blvd, Suite 3

    Edgewater , FL  32132

    386-689-9161

    nancy@holisticskincenter.com

  • All About You

  • Format: (000) 000-0000.
  • Home or Cell Phone*
  • Date Of Birth*
     - -
  • Ethnicity (To Determine Skin Types)*
  • I am interested in:*
  • Areas of Concern?*

  • Photos of Area of Concern

    Please submit clear and well lighted photos
  • I am concerned with the following:*

  • Medications

    Please check ALL that you have taken or currently taking:
  • Choose All That Apply*

  • Medical History

    Please check all conditions that apply that you have ever had or currently have:
  • Conditions*
  • Are you under a dermatologist's or other physician's care?*

  • Lifestyle Considerations

  • Have you ever had any reaction to any products or anything you have put on your face?*
  • Please check any of these you are allergic to:*
  • Do you smoke or vape?*
  • Do you use fabric softener or dryer sheets?*
  • Do you swim in a chlorinated pool?*
  • Do you work around chemicals, tars, oils, grease or inks?*
  • Do you work nights?*
  • Are you currently under a lot of stress? (common stress = job loss, new job, wedding, divorce, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)*
  • Do you use birth control pill, shots or use and IUD?*
  • Do you have shaving irritation?

  • Diet - Do you consume the following foods and/or supplements?

  • Check off foods you consume:*

  • Products Currently Using

    Please provide brands and names of products in detail

  • The Last 90 Days

    Other Treatments: What else have you done for your skin? Please be very specific.

  • I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritations to the skin from recommended regimen. The advice I receive is voluntary and I release Nancy Russ or Holistic Skin Center from Liability.

    CLIENT ASSUMES RESPONSIBILITY TO CONSULT DOCTOR FOR MEDICAL ADVICE, IF NECESSARY, PRIOR TO MAKING ANY PURCHASE.

    CLIENT acknowledges with every purchase he/she assumes full responsibility for his/her purchasing decision.

    If CLIENT has a MEDICAL condition which could be adversely affected with the use of a product or device sold here, it is the CLIENT'S responsibility to consult the appropriate healthcare provider *before* making a product or device purchase. 

    CLIENT agrees Seller and its affiliates, including any employees or contractors, are not responsible or liable, for any claim, loss, or damage resulting from use of products or devices sold here.

    ANY purchasing advice given by Seller, its affiliates, including any employees or contractors, should NEVER be considered MEDICAL advice and any advice given is NEVER intended to be MEDICAL advice or all-inclusive advice.

  • Date
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  • Should be Empty: