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Personal Profile Questionaire

If you would like to discuss an issue with your skin, health concern, or consider a maintenance regimen for healthier, younger looking skin, fill out this survey. One of our specialists will contact you with a response to your concerns.

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Thank you. Please enter your information so we may contact you:
There was a problem with your submission. Please answer the question(s) highlighted in red.
Do you consider your skin: (check one)


Describe your skin: (check all that apply)
Normal
Oily
Dry
T-Zone Combination
Freckled
Sun-Damaged
Uneven/Blotchy
Mature
Wrinkled
Saggy
Firm
Large Pores
Small Pores
Acne
Millia
Comedones
Occasional Breakouts
Scarred
Cystic
Meslasma
Florid
Rosacea
Asphyxiated
Sallow
Perfume-Stained
Hyperpigmented
Post Inflammatory Hyperpigmented
What is your Eye Color?







What is your Hair Color?









What is your Skin Tone?








What is your Heritage?
Are you allergic to (check all that apply)









Are you using Retin A?


If so, how frequently? (optional)

Where do you apply it? (optional)

Are you using Accutane?


If so, which ones? (optional)

How does your skin react to them? (optional)

Are you using Hormones or other similar medications?


If so, which ones? (optional)

How does your skin react to them? (optional)

Are you using Glycolic/AHA home care products?


If so, which ones? (optional)

How does your skin react to them? (optional)

Have you ever used any products that caused a bad reaction?


If so, describe (optional)

How do you rate your stress level?



Have you ever had a peel?


If so,what kind/products? (optional)

Describe your reaction. (optional)

Are you...? (check all that apply)
A Smoker
Getting Cold Sores/Fever Blisters
Having an issue with Telangiectasia/Broken Surface Capillaries
Getting Facial Waxing/Electrolysis or use Depilitories
Participating in vigorous aerobic activities or sports
In any stage of or have any symptoms of menopause
Recently facially post-operative
Pregnant
Currently having Sun or Wind Burn
Using tanning booths
Recently obtaining Collagen Injections
None of the above
What about your skin bothers you and what would you like to have corrected:
Describe your reaction.


First Name *
Last Name *
Email *
Phone *
Comments

Thank you. A specialist will go over your information and be in contact.