Your Name (required)

DOB (required)

Age (required)

Address

Phone (Home)

Phone (Cell)

Email (required)

Type of Work (if applicable)

Allergies

Medications

List of medical conditions esp skin cancer history, neuromuscular disorder, autoimmune illness, diabetic

Recent surgeries

Followed by a dermatologist?

Have you ever had a cosmetic procedure or treatment done? Cosmetic surgery? If yes then when

Were you happy with the results? If not why?

What is your goal for this consultation?

Do you have a specific treatment in mind?

When you look in the mirror do you see something that you would like to change or improve? If yes please explain.

Do you ever feel like you look tired/angry/sad?

What is your normal skin care routine? What products do you use? Do you wear daily makeup?

Are you someone who would prefer to not have to wear any foundation or do you like the appearance of flawless make up enhanced skin?

Do you travel a lot?

Do you smoke?

Do you have a regular exercise routine? Does it take place primarily inside or outside?

When you are outside at the hottest time of the day without sunscreen, will you burn then peel/burn then slightly tan over time/ burn then be tanned by the next day/ never burn

What is your heritage? ( if you know it)

Are you pregnant or trying to get pregnant?

What day and time of day is best for you for a possible appointment?

Are you able to do a face time consultation?

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