Skin Consultation

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Home > Skin Consultation

Skin Consultation

Full Name

Email address

What is your main skin care concern and how can we best assist you with your skincare needs?

Which product line are you most interested in? Dermalogica, CosMedix, Physician's Choice (PCA), Joey New York, Eminence, Wilma Schumann, Skin Fitness, or other.

	Hereditary Makeup:

Select Eye Color

	Blue
	Green
	Hazel
	Light Brown
	Med Brown
	Dark Brown
	Black

Select Natural Hair Color

	Blonde
	Red
	Light Brown
	Med Brown
	Black
	Gray
	Silver
	White

Select Skin Tone

	Pale
	White
	Light
	Medium
	Reddish
	Freckled
	Light Olive
	Med Olive
	Dark Olive
	Light Brown
	Med Brown
	Dark Brown
	Soft Black
	Black Sallow

What is your Birth Year?

Are you currently or within the last year under a doctor’s care?

	Yes
	No

If yes, specify.

Have you undergone any surgery in the last nine months?

	Yes
	No

If yes, specify.

Are you are seeing a dermatologist?

	Yes
	No

If yes, specify:

Do you have any allergies?

	Yes
	No

If yes, specify:

Are you taking any medications?

	Yes
	No

If yes, specify:

Are you pregnant or trying to become pregnant?

	Yes
	No

Are you lactating?

	Yes
	No

Are you taking birth control medication?

	Yes
	No

Are you experiencing Peri-Menopause or Menopause?

	Yes
	No

Do you experience ingrown hairs?

	Yes
	No

Do you experience skin breakouts?

	Yes
	No

If yes, specify:

Do you experience oilyness on your face during the day?

	Yes
	No

If yes, specify:

Is your skin sensitive?

	Yes
	No

Do you experience skin redness?

	Yes
	No

If yes, specify:

Do you have tendency to cold sores/fever blisters or herpes?

	Yes
	No

If yes, specify:

Have you had chemical peels?

	Yes
	No

Do you use Retin A, Renova, or Differin?

	Yes
	No

If yes, specify:

Have you ever used Accutane?

	Yes
	No

If yes, specify:

Do you use soap on your face?

What brand of skincare product are you currently using?

Do you wear foundation makeup?

	Yes
	No

Do you use fabric softener?

	Yes
	No

Do you smoke?

	Yes
	No

Do you exercise regularly?

	Yes
	No

Do you have regular sleep habits?

	Yes
	No

Do you use tepid water when you cleanse?

	Yes
	No

Tell us about your skin’s condition

	Sensitive
	Resilient
	Thick
	Thin
	Saggy
	Firm
	Normal
	Dry
	T-Zone Oil
	Oily
	Acne
	Comedones
	Milia
	Cysts
	Breakouts
	Acne Scarred
	Large Pores
	Small Pores
	Florid
	Rosacea
	Eczema
	Freckled
	Sun-damaged
	Unenven Blotchy
	Mature
	Wrinkled
	Patchy dryness
	Sallow
	Melasma
	Perfume Stained
	Hypo-pigmentented
	Hyper-pigmented
	Asphyixated
	Telangiectasia