Skin Consultation

1. Tell us about your skin. Select all that apply (required)
NormalDry (tight itchy )SensitiveOily SkinOily T Zone

2. Tell us about your current skin condition (required)
dehydration (flaky skin)milia (hard blackheads beneath the skin)

3. Tell us about your skin sensitivity (required)
Normal (meaning none)SensitiveVery Sensitive

4. What areas have this skin sensitivity? (required)

5. Are you experiencing any breakouts (required)
No breakouts at this timeAcne (cystic) 2Acne BreakoutsOccasional BreakoutsHormonal Break outs

6. Where are blackheads on your skin?

7. Are you experiencing acne rosacea? (required)
YesNo

8. Which acne medications have you been prescribed? Select all that apply. (required)
Topical Vit A eg RetinalVit A warrants ie different gelBenzoyl peroxideAzelaic AcidSalicylic AcidAlpha Hydroxy AcidOral antibioticsI am not currently using any medicationsI was prescribed something else

9. Tell us about your skin type (required)
Type I burns easilyType ll usually burnsType lll Sometimes burnstype lV rarely burnsType V Brown skinType Vl Dark skin

10. Are you prone to keloid scarring? (required)
YesNo

11. Do you have Eczema/Atopic Dermatitis or Psoraisis? (required)
YesNo

12. Have you ever used Vitamin A products? (required)
YesNo
if so which brand (required)

13. Are you pregnant or breastfeeding? (required)
YesNo

Your Name (required)

Your Email (required)

Your Phone Number (required)

If you have a selfie of the problem area please attach

Any additional information you want to share

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