• Skin Care 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 received any of these hair removal services on you face in the last 30 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?
  • Are you currently pregnant?
  • Would you like a "silent appointment"? I understand that we may need a moment to ourselves. By clicking yes, I will keep all conversations to a minimum & allow you to fully enjoy your service! No hard feelings at all :)*
  • Do you give permission for photos/videos to be taken during your treatment, which may be used for social media and educational purposes*
  • Should be Empty: