Skin Analysis

  • Skin Analysis

    Consultation Form
  • Date*
     - -
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • How did you hear about me?

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?
  • What Skin Care Products do you currently use?*

  • If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals. 

  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?
  • Are you a smoker?
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
  • Please rate your stress level

  • FEMALE CLIENTS

  • Are you taking birth control?
  • Are you pregnant or trying to become pregnant?
  • Any menopause issues?
  • Are you undergoing any hormone replacement therapy?

  • MALE CLIENTS

  • What is your current shaving system?
  • Do you experience irritation from shaving?
  • Should be Empty: