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Skin Consultation

Feel free to call us if you'd prefer a phone consultation or assistance. 866.407.6543

  Full Name

Email address

What is your main skin care concern and how can we best assist you with your skincare needs?

Which product line are you most interested in? Dermalogica, CosMedix, Physician's Choice (PCA), Joey New York, Eminence, Wilma Schumann, Skin Fitness, or other.

  Hereditary Makeup:
   

Select Eye Color
Blue    
Green    
Hazel    
Light Brown    
Med Brown    
Dark Brown    
Black    

Select Natural Hair Color
Blonde    
Red    
Light Brown    
Med Brown    
Black    
Gray    
Silver    
White    

Select Skin Tone
Pale    
White    
Light    
Medium    
Reddish    
Freckled    
Light Olive    
Med Olive    
Dark Olive    
Light Brown    
Med Brown    
Dark Brown    
Soft Black    
Black Sallow    

What is your Birth Year?

Are you currently or within the last year under a doctor’s care?
Yes    
No    

If yes, specify.

Have you undergone any surgery in the last nine months?
Yes    
No    

If yes, specify.

Are you are seeing a dermatologist?
Yes    
No    

If yes, specify:

Do you have any allergies?
Yes    
No    

If yes, specify:

Are you taking any medications?
Yes    
No    

If yes, specify:

Are you pregnant or trying to become pregnant?
Yes    
No    

Are you lactating?
Yes    
No    

Are you taking birth control medication?
Yes    
No    

Are you experiencing Peri-Menopause or Menopause?
Yes    
No    

Do you experience ingrown hairs?
Yes    
No    

Do you experience skin breakouts?
Yes    
No    

If yes, specify:

Do you experience oilyness on your face during the day?
Yes    
No    

If yes, specify:

Is your skin sensitive?
Yes    
No    

Do you experience skin redness?
Yes    
No    

If yes, specify:

Do you have tendency to cold sores/fever blisters or herpes?
Yes    
No    

If yes, specify:

Have you had chemical peels?
Yes    
No    

Do you use Retin A, Renova, or Differin?
Yes    
No    

If yes, specify:

Have you ever used Accutane?
Yes    
No    

If yes, specify:

Do you use soap on your face?

What brand of skincare product are you currently using?

Do you wear foundation makeup?
Yes    
No    

Do you use fabric softener?
Yes    
No    

Do you smoke?
Yes    
No    

Do you exercise regularly?
Yes    
No    

Do you have regular sleep habits?
Yes    
No    

Do you use tepid water when you cleanse?
Yes    
No    

Tell us about your skin’s condition
Sensitive    
Resilient    
Thick    
Thin    
Saggy    
Firm    
Normal    
Dry    
T-Zone Oil    
Oily    
Acne    
Comedones    
Milia    
Cysts    
Breakouts    
Acne Scarred    
Large Pores    
Small Pores    
Florid    
Rosacea    
Eczema    
Freckled    
Sun-damaged    
Unenven Blotchy    
Mature    
Wrinkled    
Patchy dryness    
Sallow    
Melasma    
Perfume Stained    
Hypo-pigmentented    
Hyper-pigmented    
Asphyixated    
Telangiectasia    


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