Name:

Email:

Sex: Select Male Female

Age: Select Under 20 20 to 29 30 to 39 40 to 49 50 to 59 60+

Location (City/State):

What is your complexion? Select Fair Light Olive Medium Dark

What is your skin type: Select Normal Dry Oily Sensitive Combination Mature

Which of the following issues do you have? (Check all that apply)

Skin reacts or irritates easily to touch and skin care products
Face turns red or flushes frequently
Rosacea
Have a history of allergies (internal/external) and/or hives
Irregular breakouts
Frequent breakouts
Acne
Enlarged pores
Have red spots or discoloration from previous blemishes
Acne scarring
Oily t-zone (forehead, nose and chin)
Oily and shiny all over the face
Skin becomes dry and/or irritated when using acne products
Eczema
Dermatitis
Psoriasis
Skin feels dry and tight, sometimes itches
Have areas of flaking, peeling or cracking
Skin still feels rough and dry after applying moisturizers
Dark circles under eyes
Puffiness around eyes
Fine lines (especially around eyes, lips and forehead)
Loss of firmness
Sagging jawline
Wrinkles
Brown spots or areas of hyperpigmentation on face and/or neck
Rough or uneven skin texture
History of skin cancer

Other, please describe:

Rate your use or exposure to the following:

Are you currently pregnant or nursing? Select Yes No

How regularly do you practice a skin care routine?
This might include cleansing, toning, moisturizer or use of other facial treatments.

Select Once per day Twice per day A few times per week Infrequently or never

Please list the products (brand/name) you currently use for skin care:

Describe any known allergies to skin care ingredients, foods or other:

Please use the section below to share any other information you feel is relevant to your situation or ask the esthetician any questions: