Please answer the following questions so that there will be a better understanding of your current skin condition, general health and lifestyle, thereby allowing for better assessment and analysis of your skin care needs.
Items marked with an * are required fields.
* First Name
* Last Name
* Email Address
* Phone Number
* Age
* Gender Male Female
Please check if presently using any of the following.
Ethnic Background
Skin Type
I have had the following procedures
* Which conditions do you want to improve?
Cause
How long have you had this discoloration?
Hydroquinone use - past and present
Are you using any other lighteners?
Area of Hyperpigmentation
Type of sun protection
Do you sunbathe or participate in outdoor activities?
Do you have or have you ever had acne?
Acne Conditions
Are you using or have ever used any medications for acne? Name of Medication?
Have you seen a Dermatologist in the past year? If yes, list doctors name and reason for visit.
Are you presently under a doctor's care?
Have you ever had an allergic reaction to any skin product or cosmetic?
Specific skin problems
Skin Texture
Skin Irregularities
What medications do you take on a regular basis?
Are you presently under a physician's care for any reason?
If yes, explain:
Do you use Biore or snore strips?
Are you allergic to aspirin?
Do you have any other allergies?
If yes, list:
Do you smoke?
Do you take nutritional supplements?
Are you currently having any facial treatments done?
How is your general health?
*What skin care products are you currently using?
What is it about your skin you would like to change?
Female Clients Only:
Are you on hormone replacement therapy?
Are you presently taking birth control pills?
Are you pregnant or planning to be?
Disclaimer: Answering these questions provides information that will act as a general guide to suggest possible use of some home care skin nutrition and possible referral for professional treatments.