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Skin Care
Skin Care Consultation Request
First name
Last name
Phone
Email
Tell me about your skin. What is your chief complaint pertaining to your skin?
Do you suffer from any of the following skin problem or concerns?
Yes
No
Are you currently seeing a dermatologist or esthetician?
Yes
No
What products are you currently using?
Are you using products containing glycolic acid or retinol?
Yes
No
Are you on acutance or using any acne medications?
Yes
No
Are you currently on Birth Control?
Yes
No
Are you on Hormone Replacement Therapy?
Yes
No
Please list any previous facial treatments or surgeries.
Do you use tanning beds?
Yes
No
To determine your Fitzpatrick Type. What is your race or ethnicity?
When you go out in the sun, do you:
Always burn
Usually burn
Sometimes burn
Rarely burn
Never burn
Do you use sunscreen daily?
Always
Sometimes
Never
Are you currently experiencing stress?
Yes
No
How do you feel about the overall quality of your Skin on a scale of 1-10. One being Bad and ten being Fantastic.
What is your skin type?
Oily
Acne/Acne Prone
Normal
Dry/Dehydrated
Rosacea
Sensitive
I don't know