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Skin Care Consultation
Need some help with your skin! We are here to help. Please be as detailed as possible so we can give you the best recommendations possible!
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Age
*
Your answer
Phone # - If you would like to receive a follow up call
Your answer
Have you had a facial treatment before?
*
Yes
No
If Yes, when was your last treatment?
Your answer
What was the focus of that treatment?
Your answer
I would describe my skin as
*
OIly
Dry
Combination
Sensitive
Other:
How long after you cleanse your skin do you notice oil?
*
Never
Within the hour
2-4 hours later
End of the day
Other:
Which of the following best describes your skin?
*
I Creamy complexion Always burns easily, never tans
II Light Complexion Always burns, tans slightly
III Light/Matte Complexion Burns moderately, tans gradually
IV Matte Complexion Seldom burns, always tans well
V Brown Complexion Rarely burns, deep tan
VI Black Complexion Never burns, deeply pigmented
On a scale of 1-10 how would you rate the overall health and appearance of your skin?
*
Needs a Complete Overhaul!
1
2
3
4
5
6
7
8
9
10
Perfect!
What does a "10" look like to you?
*
Your answer
What would you like your skin to be on a scale of 1-10?
*
Needs a Complete Overhaul
1
2
3
4
5
6
7
8
9
10
Perfect
By When?
*
As Soon As Possible
3 months
6 months
However long it takes
No specific time frame
Other:
Do you have any special skin problems or concerns?
Your answer
Do you use Retin-A, Renova, Acutane, Adapalene Hydroxy Acid or Retinol/vitamin A derivative products?
*
Yes
No
If Yes, please list
Your answer
Please list any acne medication (internal or topical)
Your answer
What areas of concern do you have regarding your skin?
*
Uneven Skin Tone
Breakouts/ Acne
Blackheads / Whiteheads
Excessive Oil
Rosacea
Broken Capilaries
Redness / Ruddiness
Sun Spot / Liver spot / brown spot
Sun damage
Wrinkles/Fine lines
Dull / Dry Skin
Flaky Skin
Dehydrated
Ingrown Hairs
Irritation
Sensitivity
None
Other:
Required
What areas of concerns for you Eyes?
*
dehydrated
wrinkles
puffiness
dark circles
None
Other:
Required
What are areas of concern for your Lips?
dehydrated
cracked/ Chapped
None
Fine Lines
Other:
Current Skin Care Routine
Please answer the following as detailed as possible (brand name, type, etc)
Cleanser
Your answer
Toner
Your answer
Serum
Your answer
Scrub/Exfoliant
Your answer
Day Moisturizer
Your answer
SPF
Your answer
Night Cream
Your answer
Eye cream
Your answer
Makeup
Your answer
Other
Your answer
On a scale of 1 to 10 how well do you think your skin care products are helping with the concerns you listed?
*
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
What results would you like your products to give you that they are not giving you now?
Your answer
Do you have any allergies?
*
Yes
No
If Yes, to what ingredients?
Your answer
Have you ever had a reaction to a skin care product?
*
Yes
No
Maybe
If yes, or maybe, please explain
Your answer
Are you pregnant?
*
Yes
No
Maybe
N/A
How would you like us to follow up with you?
*
Phone
Email
Required
Send me a copy of my responses.
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