SKYNTROLOGY Skin Consultation Form

Skin Consultation

Let's create your customized skin care system!
We are bringing you the best of both nature and science!
Welcome to SKYNTROLOGY & XHLSKIN🌱

🫧Our Plantbased company expanded to offering luxury skincare with our Licensed Advanced Esthetician & Alternative Medicine Practitioner!

🫧These products offer complete solutions for radiantly, beautiful, skin that inspires confidence at any age.

🫧Harnessing the natural power of revitalizing botanical oils, nutrient-rich exotic fruits, plant-based stem cells, and a rejuvenating exclusive vegan ingredients & combining alternative medicine and conventional, SKYNTROLOGY offers the most advanced approach to healing Acne , Hyperpigmentation , PCOS & anti-aging in skincare available today.

🫧The questions below will ensure you are set up with the customized skin care system specific to you, designed to give you the best skin of your life!

We're happy to have your here :)

🫧 Let's get started!
Date

MonthDayYear
Date
What's your Name?*

First NameLast Name
Email*
example@example.com
Phone Number*
How old are you ?*
Are your pregnant ?*

YesNo
Do you think you have:*

Dry SkinOily SkinCombination SkinNormal SkinHyper-allergenic SkinOther
Do you have any current Skin Medical Conditions ?*

EczemaRosaceaCystic AcneCold SoresPsoriasisNone
Do You Have (select all that apply):*

Sun DamageAge SpotsFine Lines & WrinklesAcne or Large PoresDiscolorationDark Circles or Puffiness Under the EyesAcne scarsHyperpigmentationInflamed or Active AcneOther
Have you’ve had any of the following treatments in the last 6 months ?*

Chemical peelsMicroneedlingDermaplaningBotox or FillersFacialOther
What Would You Like to Change/Improve or Are there any specific areas of concern?*
What are Your Skin Goals?*
What Products are You Currently Using?*
Do you consume a lot of dairy or processed foods? *
Have you experienced any of the following reactions to facial treatments or products*

Redness or irritationBreakouts or acne flare-upsItching or burning sensationExcessive dryness or flakingSwelling or puffinessRash or hivesIncreased sensitivity to the sunNo adverse reactionsOther
Do you have any known allergies? (skin or otherwise) Please list below !*
Are there any particular areas you would like us to focus on?*
Sunscreen Use: Do you wear sunscreen daily?*

YesNo
Are you okay with being recorded? (Your Privacy Is our biggest concern)*

YesNoOther
Are you okay with being posted ? (We post before and afters on our social media accounts ; TikTok and Instagram)*

YesNo
How did you find us ?*
Lifestyle and Additional Information: How often do you experience skin issues such as breakouts or irritation?*
Are you taking any medications (prescription or over-the-counter) that might affect your skin? (Check all that apply):*

Retinoids (e.g., Retin-A, Tretinoin, Differin, Accutane)Antibiotics (e.g., Doxycycline, Minocycline, Clindamycin)Birth control or hormone therapyBlood thinners (e.g., Aspirin, Warfarin)Steroids (e.g., Prednisone, Hydrocortisone)Anti-inflammatory medications (e.g., Ibuprofen, Naproxen)Antihistamines (e.g., Benadryl, Zyrtec, Claritin)Diabetes medications (e.g., Metformin, Insulin)Thyroid medications (e.g., Levothyroxine)Chemotherapy or immunosuppressive drugsNoneOther
Consent & Acknowledgment: • I understand that the information provided is truthful and confidential and will be used solely to customize my facial treatment. • I acknowledge that individual results may vary and that all recommendations are based on the details provided. • I agree to immediately inform my esthetician of any discomfort or adverse reactions during the treatment. • I will notify my esthetician of any changes to my skin condition or overall health. *

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