1. Name: (required)              

 2. Email Address: (required)  

 3. Address:   City  State Zip

 4. Phone Number:   Best time to reach you? Time Morning Daytime Afternoon Evening

 5. What are your biggest concerns regarding your skin (check all that apply)?

 6. How would you best describe your skin (check all that apply)?

 7. What products do you wash with?

 8. What moisturizer do you use?

 9. Question?

10. Do you spent a lot of time outdoors? Yes No

11. Do you wear sunscreen? Always Sometimes Never

12. Do you go to tanning booths? Frequently Sometimes Never

13. Do you smoke? Yes No

14. Are you currently using Retin-A or Renova? Yes No

15. If so, how long have you been using it?
under 3 months 3 months-1 year 1-3 years over 3 years

16. Do you experience any irritation, dryness or flakiness from Retin-A?
Yes No

17. Are you currently using the drug Accutane? Yes No

18. Have you undergone laser skin resurfacing in the last 3 months?
Yes No

19. Do you have allergies to any of the following?
Alpha-hydroxy acids Hydroquinone Preservatives Fragrances

20. List any other known allergies: (optional)