Name

Email

Phone

Your Age is:

Your Sex is:

1. Which of the following most closely describes your skin tone:

2. Which of the following best describes your skin type?

3. Does your skin break out?

4. How would you describe your skin?

5. Do you have small, red, broken blood vessels on your face?

6. Do you spend a lot of time outdoors?

7. Do you wear sunscreen?

8. Do you have any "age spots" or sun damage on your face?

9. Do you smoke?

10. Are you currently using the drug Accutane?

11. Have you undergone laser skin resurfacing in the last 3 months?

12. Do you have allergies to any of the following?

13. List any other known allergies: (optional)

14. Do you have a regular skin care routine now?

15. What type of a cleanser are you using?

What line(s) of skin care products are you currently using? (optional)

17. What kind(s) of results are you looking for? (Check all that apply)