Skin Care Consultation Request





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?


Are you currently seeing a dermatologist or esthetician?


What products are you currently using?

Are you using products containing glycolic acid or retinol?


Are you on acutance or using any acne medications?


Are you currently on Birth Control?


Are you on Hormone Replacement Therapy?


Please list any previous facial treatments or surgeries.

Do you use tanning beds?


To determine your Fitzpatrick Type. What is your race or ethnicity?

When you go out in the sun, do you:






Do you use sunscreen daily?




Are you currently experiencing stress?


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?