SKIN ANALYSIS CONSULTATION FORM
FIRST NAME : _________________ LAST NAME : ___________________
PHONE : _________________ AGE : _________
[
] MALE [
] FEMALE
DATE : ______________
ABOUT YOUR SKIN
INDICATE YOUR CONCERNS BELOW.
SKIN CARE ROUTINE
TELL US WHAT YOU USE ON YOUR SKIN.
[ ] WRINKLES AND FINE LINES
CLEANSER: ____________ [
] GEL [
] MILK [
] CREAM
[ ] LACK OF TONE, SAGGINESS
EXFLOIATE: _________________ [
] ENZYME [
] SCRUB
[ ] REDNESS
MASK: _________________ [
[ ] BROWNSPOTS
TONER: ________________________
[ ] BLEMISHES (COMEDONE, ACNE)
SERUM: ________________________
[ ] EYE CONTOUR AREA (PUFFINESS, DARK CIRCLES)
EYE CARE: ____________________ [
[ ] COMPLEXION, DULL, SALLOW
MOISTURIZER: ___________________
[ ] SENSITIVITY
SUN CARE: ______________________
] GEL [
] CLAY [
] SERUM [
] CREAM
] CREAM
[ ] SUN EXPOSURE (VACATION) : __________
ADDITIONAL ADVICE:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
TREATMENT SUGGESTIONS:
___________________________________________
___________________________________________
___________________________________________
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CLIENT’S LABEL