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Use Discount Code: RELAX for 30% off when you purchase any Service Series. (Service Series includes a package of 4 treatments to be used within 6 months)

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Skin Analysis Form

Fill out the Skin Analysis form to help our estheticians best decide how to help you!

First Name

Last Name

Date of Birth

Occupation

Cell Phone

Home Phone

Work Phone

Your Address

How do you wash your face?

Soap

Cleanser

Soap Brand

Cleanser Brand

Do you use a moisturizer?

Yes

Do you use Glycolic Acid on a regular basis?

Yes

Have you or are you currently using Retin A?

Yes

Are you/have you taken accutane?

Yes

If yes, please specify:

Are you currently taking any medication?

Yes

Do you ever have burning/itching on your skin?

Yes

If yes, please specify:

Are you allergic to anything?

Yes

If yes, please list:

Do you experiece redness/irritation often?

Yes

Do you have heart trouble?

Yes

Are you a diabetic?

Yes

Do you consume water daily?

Yes

If yes, how much?

Are you on a special diet?

Yes

Do you drink coffee, tea, or soda daily?

Yes

If yes, please specify:

Coffee oz

Tea ozs

Soda ozs

Do you exercise?

Yes

Do you give yourself a facial at home?

Yes

If yes, how often?

Have you ever had a facial?

Yes

If yes, when was your last facial?

Please list cosmetics and skincare products you are currently using:

Your Signature

Thanks for submitting! One of our specialists will get in touch with you as soon as possible.

Esthetician comments/treatment plan:

Subscribe For Updates!

Thanks for submitting!

(901) 490-1530

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