SKINCARE CONSULTATIONHome>Skincare ConsultationConsultation Form"*" indicates required fields Step 1 of 616%PERSONAL DETAILSFirst Name*Last Name*Email* Phone*DOB* MM slash DD slash YYYY Address* Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands How did you learn about us?*UPLOAD YOUR PHOTOSTo help achieve your skin goals, please answer the following questions and provide photos taken in natural light without makeup or filters. Include one photo of your face from the front and each side. Ensure visibility of your neck in the photos or take separate ones if needed. Zoom in to capture your pores clearly. If applicable, include photos of specific problem areas like the forehead, cheeks, or neck. Providing more photos is preferred.Upload Drop files here or Select filesAccepted file types: jpg, jpeg, png, Max. file size: 6 MB, Max. files: 6.SKIN DETAILSYour skin type* Oily Dry Sensitive Skin Normal CombinationWhat are your skincare challenges ?* Acne/Acne Scarring Aging/Wrinkles/Fine Lines Eczema Hyperpigmentation Hypopigmentation Ingrown Hair Melasma Psoriasis Sensitivity/Rosacea Scarring OtherPlease specify if other*I am currently using* Renova (tretinoin) Adapalene Accutane Differen Glycolic Acid Lactic Acid Mandelic Acid Retinol Other Vitamin A derivatives Hydroquinone OtherPlease specify if other*How long have you been using it?*What's the name, type, and brand of the product you're currently using*Upload Product Photos Drop files here or Select filesAccepted file types: jpg, png, jpeg, Max. file size: 10 MB.Do you currently use makeup ? Yes No SometimesIf yes or sometimes, kindly provide details such as the product name, brand, and type.I have received these Treatments* Facial Chemical Peel Microdermabrasion Microneedling Laser Services Botox Filler NoneWhen was your last treatment?*I have undergone the following facial hair removal services* Waxing Sugaring Threading Electrolysis / Laser Depilatory Cream Shaving NoneIf yes, please indicate when your last service was and how often are you doing them?*HEALTH AND DIETARYI have health issues related to* Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart Problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters / Herpes / Frequent Cold Sores HIV/AIDS Lupus Depression / Anxiety Hepatitis Headaches / Migraines Other NonePlease specify if other*If yes, please provide more information about your specific health condition(s)*Please mention prescription medication you are currently taking (if any)I take the following dietary or health supplements* Multivitamin Vitamin C Vitamin D/D3 Zinc Omega 3 / Fish Oil B Complex / B12 Garlic Calcium Folic Acid Melatonin Coenzyme Q10 Biotin Other NoneIf selecting "Other," please specify.*Have you used or been prescribed any medications (topical or oral) for acne / acne control? If yes, please specify itI am allergic to* Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other NoneIf choosing Yes or Other, please indicate if you are currently under medication, and specify any other allergies*Are you a smoker?* Yes No SocialDo you drink more than 4 caffeinated beverages a day?* Yes NoPlease rate your stress level* Low Medium HighADDITIONAL DETAILS( For female clients only )Are you taking birth control? If yes, please specify itAre you pregnant or trying to become pregnant? Yes No N/A Recently had a baby and am breastfeedingAny menopause issues? If yes, please specify itAre you undergoing any hormone replacement therapy? If yes, please specify itADDITIONAL DETAILS( For male clients only )What is your current shaving system?* Razor / Wet shave Electric N/ADo you experience irritation from shaving?* Yes No N/A