Free Online Skin Consultation

Full Name

Email Address

Phone Number

What are your skincare goals?

What are your skincare challenges?
—Please choose an option—Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther

Have you ever had a facial treatment before?
YesNo

What skin care products do you currently use?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)

If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?
—Please choose an option—Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure

Do you wear and SPF Moisturiser?
YesNo

Do you exfoliate the skin on a weekly basis?
YesNoSometimes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.