Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
Email
*
Occupation
*
Ethnicity
*
Skin
*
Check the areas you would like to improve your skin
List skin products currently using:
*
Have they achieved the results you want?
*
Do you use sunscreen daily?
*
Body
*
Check the areas you would like more information on or are interested in:
List body products you currently are using:
*
Have they achieved the results you want?
*
Do you smoke?
*
Have you in the past or present or had any of the following problems?
*
Please note other if not listed above:
Have you had plastic surgery?
*
If you have had plastic surgery, please tell us the date, surgeon's name and a description:
Are you currently using Retin-A, Retinal, AHA or any peeling agent?
*
If so, how long, what strength and what results:
Do you suffer from claustrophobia or anxiety?
*
Any known allergies to: Cosmetics, Food, Medication, Animals, Pollens or Metals?
*
If yes, please list:
Do you have a tendency to keloid scar?
*
Have you had a skin peel in the past 2 years?
*
If yes, please share results and brand:
Have you been under a physicians care during the past 3 years?
*
Are you currently taking medication?
*
If you are, please let us know how long and name the medication:
Are you currently taking accutane or roaccutane?
*
If you are, how long for?
Dietary, Herbal Supplements or Vitamins:
*
If yes, please let us know how long and name them:
How much water do you drink daily?
*
Date
*
Thank you for submitting your information.
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