To assess which skincare is best suited to you, please fill out this consultation form & attach any photos of your skin (optional) & send to email@example.com with your name as the subject.
Date of Birth:
Does your job require that you work outdoors? No Yes
What would you like to achieve with your skincare?
Your Skin Care
1 - Have you ever had a facial treatment before?
No Yes, when?
2 - Do you have any skin problems or concerns to your face or body?
3 - Have you ever had chemical peels, laser or microdermabrasion or other skin treatments? No Yes
In the last month? No Yes
If yes, what did you have?
4 - Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? No Yes
5 - Have you used any of these products in the last 3 months? No Yes
6 - Have you used an acne medication? No Yes,
when? Which one?
7- What skin care products are you currently using? (List brand where known)
8- Have you recently used any self-tanning lotions, creams or treatments? No Yes, specify:
9- Have you used any of the following hair removal methods in the past six weeks on your face?
No Yes, circle all that apply.
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
10- What areas of concern do you have regarding your: Skin:
(Please check any that apply and explain)
Dehydration, wrinkles, puffiness, dark circles Other:
Dehydrated, cracked/chapped lips, Other:
Dehydration, wrinkles, puffiness, dark circles, congestion, open pores
11- Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
If yes, please explain:
Shower Gels or soap -
Body Lotions -
Circle any that apply:
Sun spot/liver spot/brown spot
Uneven skin tone
Female Clients Only:
12 - Are you taking oral contraceptives? No Yes
13 - Any recent changes to or from your contraceptive treatment?
If so, what and when:
14- Are you pregnant or trying to become pregnant? No Yes
15- Are you lactating? No Yes
16- Any menopause problems? No Yes
17- Are you undergoing any hormone replacement therapy? No Yes
Male Clients Only:
18- What is your current shaving system?
Wet shave Electric
19- Do you experience irritation from shaving? No Yes Ingrown hairs? No Yes
The following factors are potential triggers for breakouts & acne -
1. Diet, Allergies & Medication
2. Physical Health & Exercise
3. Mental health
4. Internal & External factors
5. Environmental triggers, including UV, pollution, pesticides
6. Toxic exposure to inflammatory chemicals, preservatives, irritatation of skincare/makeup.
Please use this space to complete answers where space was insufficient. Please include the number of the question & your concerns relating & any other information you want to specify or address.