Profile

Name:  

DOB:  

Phone Number:  

Gender:  

Occupation:  

Skin History

How would you describe your skin type?

 

What condition would you like to improve about your skin? Please check all that apply

If Other, describe here  

Approximately when was your last your facial?:   

How often do you get facials?:  

Describe generally ideally what you would like to achieve with your skin  

Please describe any any exfoliation i.e. chemical peels, scrubs, retinol you have done within the last week? It is recommended to stop exfoliants at least 48 hours and ideally 1 week prior to your facial.   

Which one of the following best describes your skin?

 

Health History

What is your ethnic background?  

Have you seen a dermatologist in the past year? choose one

 

Are you currently taking any medication or supplements we should be aware about? Please list them here, if none enter none:  

Please list any illnesses or pre-existing conditions that we should be aware about here:  

ALLERGIES: please list any known allergies here:  

Home Care

What skin products are you currently using at home. Check all that apply

 

Do you use sun protection?

 

Do you sun bathe?

 

Do you use the tanning boothe?