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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? * Required

Soap

Cleanser

Soap Brand

Cleanser Brand

Do you use a moisturizer? * Required

Yes

Do you use Glycolic Acid on a regular basis? * Required

Yes

Have you or are you currently using Retin A? * Required

Yes

Are you/have you taken accutane? * Required

Yes

If yes, please specify:

Are you currently taking any medication? * Required

Yes

Do you ever have burning/itching on your skin? * Required

Yes

If yes, please specify:

Are you allergic to anything? * Required

Yes

If yes, please list:

Do you experiece redness/irritation often? * Required

Yes

Do you have heart trouble? * Required

Yes

Are you a diabetic? * Required

Yes

Do you consume water daily? * Required

Yes

If yes, how much?

Are you on a special diet? * Required

Yes

Do you drink coffee, tea, or soda daily? * Required

Yes

If yes, please specify:

Coffee oz

Tea ozs

Soda ozs

Do you exercise? * Required

Yes

Do you give yourself a facial at home? * Required

Yes

If yes, how often?

Have you ever had a facial? * Required

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:

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Thanks for submitting!

(901) 490-1530

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