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Skin Care Solutions By Marie
Virtual Consultation Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone
When would you like to attend?
*
Date
Time
Appointments can be booked from Monday to Saturdays. Sundays and holidays for emergencies only.
What kind of skin do you have?
*
- Please select -
Normal
Oily
Dry
Combination
Have you been under the care of a dermatologist or have facial spa treatments within the past year?
*
- Please select -
Yes
No
Please Explain
*
What are your areas of concern regarding your skin?
Breakouts/Acne/ Maskne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness/Rough Skin
Dehydrated
Sun, Liver, Brown Spots
None
Other
Please explain Other areas regarding your skin
*
Have you ever had an allergic reaction to any of the following?
*
Cosmetics
Medicine/Drugs
Food
Animals
Sunscreen
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
None
Other
Please explain symptoms of allergic reaction(s) or Other areas regarding your skin
*
Please briefly describe your concern
Do you currently or have you used any of the following within the last 6 months?
*
Retin-A
Peels and resurfacing treatments
Vitamin A
Vitamin C
Retinol
Botox
Restylane
Collagen injections
None
Other
Comments
By printing and signing below, you agree to the following:I have completed this form to the best of my abilities and knowledge and agree to inform Skin Care Solutions By Marie/Esthetician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatment(s) and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the Esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all the liabilities toward my Esthetician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
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