Facial Discovery Call Client Information
First Name
*
Last Name
*
Email
*
Phone
*
Date of Birth
*
Do you have any allergies to food, cosmetics, or drugs?
*
Yes
No
If yes, please list:
Do you have any of the following:
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Asthma
Diabetes
Eczema
Epilepsy
Hemophilia
Heart problems
Hepatitis
High blood pressure
HIV
Lupus
Moles
Phlebitis
Psoriasis
Skin cancer
Sunburn
None
Please list any other health conditions:
Are you pregnant?
*
Yes
No
Are you on birth control or hormone replacement?
*
Yes
No
Are you taking any supplements or medications? Please list what you take and what it's for.
Are you under the care of a skin care therapist, physician, or dermatologist?
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Yes
No
Are you or have you been using or taking any of the following?
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Acne medication
Products containing alpha-hydroxy acids
Products containing hydroquinone
Vitamin A therapies
None
Have you had any of the following procedures?
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Laser resurfacing
Chemical peel
Botox or collagen injections
No
Please list any other skin procedures here:
Date of last treatment:
Have you had a facial before?
*
Yes
No
Date of last facial:
What are your areas of concern?
*
How does your skin react to the sun?
*
Do you experience frequent blemishes? How frequently?
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Have you ever experienced burning, itching, redness, or irritation?
*
Which of the following products do you currently use?
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Cleanser
Exfoliate or scrub
Masks
Moisturizer
Soap
Sunscreen
Toner
What brand name(s)?
*
I want to get awesome health tips, tools and resources to my inbox!
*
Yes
No, thank you
Proceed to Schedule