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Free Skin Care Consultation

Perhaps you're uncertain about which products are right for your type. Or maybe you have skin care concerns or questions. Our Licensed Esthetician has over 15 years of experience and is ready to personally evaluate your skin care issues. She will offer practical advice, product recommendations and samples to help improve your situation.

Fill out the form below and the esthetician will contact you within two business days. Try to answer the questions as completely as possible for the most detailed analysis.


Name:

Email:

Sex:

Age:

Location (City/State):

What is your complexion?

What is your skin type:

Which of the following issues do you have? (Check all that apply)

Skin reacts or irritates easily to touch and skin care products
Face turns red or flushes frequently
Rosacea
Have a history of allergies (internal/external) and/or hives
Irregular breakouts
Frequent breakouts
Acne
Enlarged pores
Have red spots or discoloration from previous blemishes
Acne scarring
Oily t-zone (forehead, nose and chin)
Oily and shiny all over the face
Skin becomes dry and/or irritated when using acne products
Eczema
Dermatitis
Psoriasis
Skin feels dry and tight, sometimes itches
Have areas of flaking, peeling or cracking
Skin still feels rough and dry after applying moisturizers
Dark circles under eyes
Puffiness around eyes
Fine lines (especially around eyes, lips and forehead)
Loss of firmness
Sagging jawline
Wrinkles
Brown spots or areas of hyperpigmentation on face and/or neck
Rough or uneven skin texture
History of skin cancer

Other, please describe:

Rate your use or exposure to the following:

Salt
Sugar
Caffeine
Tobacco
Alcohol
Water
Exercise
Vitamins/Supplements
Prescription Medications
Outdoors
Sun

Are you currently pregnant or nursing?

How regularly do you practice a skin care routine?
This might include cleansing, toning, moisturizer or use of other facial treatments.

Please list the products (brand/name) you currently use for skin care:

Cleanser:
Exfoliation:
Mask:
Toner:
Moisturizer:
Special Treatments:
Other:

Describe any known allergies to skin care ingredients, foods or other:

Please use the section below to share any other information you feel is relevant to your situation or ask the esthetician any questions:

 
 

 

 

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