Consultation Form

First Name
Last Name
Email Address
Phone Number
Street Address
Two letter abbreviation for State
Accept Text Appointment Reminders
Within the last year, have you been under a dermatologist or other physician's care?
If yes, explain. (physician's care)
Within the last nine months, have you undergone any surgery?
If yes, explain. (surgery)
Have you had any health problems in the past or present?
If yes, explain. (health)
List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly. Write NONE, in none.
Do you smoke?
Do you exercise regularly?
Do you get 8 hours of sleep each night?
Do you follow a restricted diet?
How many 16 oz glasses of plain water do you consume daily?
Do you drink 4 or more caffeinated beverages daily? (i.e. Coffee, tea, soft drinks or energy drinks)
How many alcoholic beverages do you consume weekly?
Do you wear contact lenses?
Rate your level of stress on a scale of 1 (low) to 4 (high)
Do you have any special skin problems pertaining to your face or body?
If yes, explain. (skin problems)
What skin care products are you currently using on your FACE? (Check all that apply)
What skin care products are you currently using on your BODY? (Check all that apply)
Are you currently using any products that contain the following ingredients? (Check all that apply)
Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?
If yes, in the last month?
Do you use Accutane, Retin A, Renova, Adapalene or other prescription skin products?
Do you ever experience these conditions on your skin?
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your face?
Do you sunbathe or use tanning beds? (check all that apply)
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
Do you suffer from sinus problems?
Do you ever experience oily shine during the day?
Do you ever experience skin breakouts?
Do you ever experience a burning, itching sensation on your skin?
Have you ever had a reaction to any of the following? (Check all that apply)
Any allergies, not listed? Please list here, or write NONE
Are you taking oral contraception?
Are you pregnant and seeing changes in your skin?
If yes, what changes are you experiencing?
What is your current shaving system?
Do you experience irritation from shaving?
Do you experience ingrown hairs?
What are your skin care goals?
What is your preferred method of contact? (text, email, telephone)