First Name
Last Name
Phone
*
Email
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Tell me about your skin. What is your chief complaint pertaining to your skin?
Are you currently seeing a dermatologist or esthetician?
Yes
No
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What products are you currently using?
Are you using products containing glycolic acid or retinol?
Yes
No
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Are you on acutance or using any acne medications?
Yes
No
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Are you currently on Birth Control?
Yes
No
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Are you on Hormone Replacement Therapy?
Yes
No
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Please list any previous facial treatments or surgeries.
Do you use tanning beds?
Yes
No
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To determine your Fitzpatrick Type. What is your race or ethnicity?
When you go out in the sun, do you:
Always Burn
Usually Burn
Sometimes Burn
Rarely Burn
Never Burn
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Do you use sunscreen daily?
Always
Sometimes
Never
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Are you currently experiencing stress?
Yes
No
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How do you feel about the overall quality of your Skin on a scale of 1-10. One being Bad and ten being Fantastic.
What is your skin type?
Oily
Acne/Acne Prone
Normal
Dry/Dehydrated
Rosacea
Sensitive
I don't know
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