How did you hear about us?
What are your skin goals and objectives?*
What are your skin care challenges?*
If other, please explain:
Ever had a facial or skin treatment before?*
What products do you use?*
Would you like suggestions for home care products*
What is your daily skincare routine?*
Do you or have you used the following medications:*
If yes, please select frequency:
Have you ever received any if these therapies:*
Received any in the last 14 days?*
If yes, please specify treatment and date
Experienced health conditions past or present?*
Do you have cancer or recovering from cancer?
If checked yes,please provide more information.
Have you used Accutane in the past 6 months? *
If yes, please specify what and date last used
Have you had a skin exam in the past year?*
Do you need us to suggest a dermatologist?*
Drink more than 4 caffeinated beverages a day?*
Please rate your stress level:*
Females Are you taking birth control?*
Are you pregnant or trying to become pregnant?*
Females Any menopause issues?*
Undergoing any hormone replacement therapy?
Males: What is your current shaving system?*
Males: Do you experience irritation from shaving?*