Confidential Questionnaire

CONFIDENTIAL QUESTIONNAIRE

1. PERSONAL DETAILS

2. WHAT ARE YOUR MAIN AREAS OF CONCERN?

3. HEREDITARY HISTORY

4 . L I F E STYLE

   Diet and exercise

5 . CURRENT SKIN CARE

6. MEDICATIONS

Have you ever used...

7. MEDICAL CONDITIONS

Have you ever had any of the following?

8. PREVIOUS COSMETIC TREATMENTS

9. SKIN GROUPS

1 0 . SKIN TYPES

11. SKIN CONDITIONS

12. SPECIAL CAUTIONS

In our treatment program, it may be necessary to recommend alterations and/or additions to your home care
regimen. We will recommend the appropriate schedule for future facial treatments or referral in order to achieve your
skin improvement goals.

Fill out our online questionary form