pure skin science
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Skin Consultation

Confidential Skin Questionnaire

The following are questions regarding your skin condition and areas that affect your skin. We use your answers to accurately evaluate your special skin care needs and e-mail you a personalized skin care recommendation for best results with our products in 72 hours or less. We guarantee that your information remains strictly confidential, it will never be shared or sold to others and will only be used for this skin analysis.

What do you dislike most about your skin: *
Please list any Supplements and Medications you are currently taking:
Please list any allergies (cosmetics, fragrance, drugs, animals, metals etc.): *
Do you have any of the following (please list all that apply) wrinkles, sagging skin, brown spots, melasma, large pores, acne, scarring, blackheads, whiteheads,oily, dry, thinning skin, other: *
Have you had any recent facial surgery/chemical peel/ laser treatment (please list all that apply and date of treament): *
Do you experience breakthrough oily shine throughout the day (yes/no): *
Do you have extremely sensitive skin (yes/no): *
Do you have rosacea or tend to flushing and blotchy redness (yes/no): *
Are you subjected to ongoing sun exposure due to outdoor activity (yes/no): *
Do you burn easily in moderate sunlight (yes/no): *
Have you ever used prescription Retin A (yes/no, if yes, date of last use}: *
Have you ever used the acne drug Accutane (yes/no, if yes, date of last use): *
What type of skin care do you currently use (cleanser, toner, scrub, glycolic, moisturizer, sunscreen, masque, list all that apply):
What is your age?:
What is your skin color (fair, light tan, olive, dark): *
Ethnicity (white,hispanic, asian, african american, other):
Gender (male/female):
e-mail: *
What is your name?:
Address:
City:
County:
Zip:
Telephone:
How did you hear about us (internet, radio, television, magazine, referral):
What type of recommendation would you like to receive from us (in-office treatment, at-home care products, both)?

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