Skincare Assessment

Not sure what skincare you need? Please complete the following questionnaire so our skincare specialist can better develop a customized skincare routine for you. Once the form is completed, we will contact you to schedule a consultation. The skincare consultation fee is $50 and it's credited to your skincare products at checkout.

Which are you interested in learning about? (Check all that apply) *

Skin Care Products

In-Office Skin Treatments

Shipping Skin Care Products

We can only ship products within the United States.

Full Name *

Email *

Phone *

Date of birth *

Preferred Shipping Address for Purchased Products

Address *

State *

City *

Postal code *

Select your skin type below. If you are unsure, choose the one that sounds most similar to you. *

I - Pale white skin; extremely sensitive skin, always burns, never tans (example: red hair with freckles)

II - White Skin; very sensitive skin, burns easily, tans minimally (example: fair skinned, fair hair, northern Asians)

III - Light brown skin; sensitive skin, sometimes burns, slowly tans to light brown (example: darker caucasians, some Asians)

IV - Moderate brown skin; mildly sensitive, burns minimally, always tans to moderate brown

V - Dark brown skin; Resistant skin, rarely burns, tans well

VI - Deeply pigmented dark brown to black skin; Very resistant skin, never burns, deeply pigmented

The following information is essential to optimize your treatment plan.

Are you currently pregnant, actively trying to become pregnant or nursing? *

Yes

Are you currently using or have you previously used medical grade skincare? *

Yes - I used medical grade skincare in the past

Yes - I am currently using medical grade skincare

No - I have never used medical grade skincare

Other skincare products

Other prescription medications you are currently taking

Any allergies?

Have you used retinol in the past? *

Yes

Have you used hydroquinone in the past? *

Yes

In a few words, please describe your primary concerns or goals for your skin. *

Please provide one picture of your skin or problem areas, and another full face photo. (Please upload make-up free selfies with good lighting and without a filter). *

Your Experience With Skincare

What would you consider your skincare experience level? *

Beginner: I need to learn it all

Some Experience: I know the basics

Expert: I am a skincare junkie

How long is your skincare regimen? *

Short and sweet (1-3 steps)

Advanced (4-6 steps)

I understand the skincare consultation is $50 and the fee goes toward the skincare products at checkout. *

I understand.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.