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Skin Consultation Form


Please fill out the skin care client consultation form to the best of your ability. Please allow up to 5 business days for a response.

What is your skin type?
What is your Fitzpatrick Scale? (Skin Complexion)
What are your skin care concerns?
What Skin Care Products are you currently using?
Have you used Accutane, Adapalene, Differen, Glycolic Acids, Lactic Acids, Mandelic Acid, or Retinol?
Have you received a chemical peel or any laser treatments recently?
Have you used acne medication?
Have you received any Botox or dermal fillers in the past 14 days?
Do you currently have or have experienced any health conditions listed below?
Do you have any of the following?
Do you follow a healthy diet?
Do you smoke?
Do you have any allergies?
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I have read and I understand the questionnaire completely. I have answered the questions truthfully and to the best of my knowledge. I understand that if I withhold any information, that the esthetician is not held liable for any skin reactions due to misinformed information. The service treatments received from the esthetician are voluntary and I release the skincare specialist from any liability and I assume any responsibility thereof. This is not the consultation form for the Acne Bootcamp. The information provided will not be shared with any 3rd parties.


Thanks for submitting!

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