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Full Name*

Email Address*

Phone Number*

Address (Number, Street, Unit)*


Province / State*


Postal Code / ZIP*

Date of Birth

What are your current concerns with your skin?

What skincare and makeup products are you using at home now?

What results do you wish to achieve with your skin?

How much time do you spend on your skincare regimen per day?

How often do you cleanse, tone & moisturize your skin?

Around the EYE area, do you have any concerns with fine lines/wrinkles, sagging, puffiness, dark circles, dryness or rough texture?
If yes, please specify:

Do you use glycolic acid or retinol on a regular basis?

How would you rate your nutrition?
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How many glasses of water do you drink per day?

Do you take any vitamins or nutritional supplements?

Do you smoke?

Do you spend a lot of time outdoors?

Do you currently take any medications that may affect your skin?
If yes, please specify:

Do you experience any skin sensitivity? (ie. redness, itching, burning, irritation)
If yes, please specify:

Do you have any allergies?
If yes, please specify

Is there any chance you may be pregnant?

Anything else you’d like to share?

Please attach a clear photo of your face.

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