Skin Consultation

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you smoke? *

Yes

No

Have you been treated for... *

Acne

Depression

Skin Disease

High Blood Pressure

Cold Sores

Diabetes

Cancer

None of the above

Are you pregnant? *

Yes

No

Are you trying to get pregnant? *

Yes

No

Are you having hormone therapy? *

Yes

No

Are you prone to cold sores? *

Yes

No

Do you take supplements/vitamins? *

Yes

No

Do you use tanning beds? *

Yes

No

When you go out into the sun, do you (check one):

Always burn

Usually burn

Sometimes burn

Rarely burn

Very rarely burn

Never burn

Have you ever been under the treatment plan of a: *

Dermatologist

Plastic surgeon

Aesthetician

None of the above

Are you concerned about skin conditions on your body? *

Sun spots

Skin laxity

Dry / rough

None of the above

Do you use a daily environmental protection product (sunblock)? *

Yes

No

Your is your skin type? *

Normal

Dry/dehydrated

Oily

Acne/acne prone

Rosacea

What improvement to your skin would you like to see?

Reduction of fine lines

Reduction of brown spots/sun damage

Reduction of oil/acne

Acne scars diminished

Reduction of redness