PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Date of BirthPhone Number *Email Address *How did you hear about us?GoogleInstagram/FacebookFriendOther*Have you had a facial before?YesNoWhat is your main focus/concern? Is there anything you would like to specifically focus on?0 / 180 What skin care products are you currently using? (including any topicals prescribed from a doctor or dermatologist, make-up; primer, foundation, etc.) 0 / 180Are you interested in learning about new products/skincare regimen? YesNoIs dairy a part of your diet? If yes, what kind of dairy (i.e. milk, cheese, yogurt..) and how often do you consume dairy? *0 / 180In the past three months, have you received any of the following treatments or used any of the following products? *Alpha Hydroxy Acids (Glycolic or Lactic Acids)Hydroxy Acids (salicylic acids)Retinol or Retin-AApricot ScrubLaserMicrodermabrasionMicrobladingChemical PeelsFacial WaxingBenzoyl PeroxideNone of the aboveApproximately how many glasses of water do you consume daily? *12345678910Approximately how many caffeinated beverages do you consume daily? *12345Do you smoke cigarettes?YesNoIf you experience acne/break outs, what areas of the face do you break out the most?0 / 180Do you exfoliate? YesNoHow often do you exfoliate?0 / 180Do you consider yourself to have any of the following? *TightnessRednessFine lines/WrinklesDryness/FlakinessSensitivitiesVisible CapillariesBlackheadsActive Break-outs, pimples/pustulesAny known allergies?0 / 180Female ClientsAre you taking birth control?YesNoAre you pregnant?YesNoAre you going through menopause?YesNoHave already experienced menopause?YesNoClient HistoryHave you been to a dermatologist in the last 6-12 months?YesNoIf you have seen a dermatologist in the last 6-12 months, what was it for, and were you prescribed any topical or oral medications?0 / 180Do you have any of the following issues?CancerHormonal ImbalancesPsoriasisCold SoresHigh Blood PressureThyroidRecent SurgeriesMetal ImplantsEczemaNone of the aboveDateHoursMinutesAMPMConsent FormI agree to the terms