French skincare home regimen consultation form

Please email back with picture of your skin to lefrenchskincare@gmail.com

All your information is confidential and will not be shared.

NAME _____________________

CELL PHONE _____________________

EMAIL_______________

BIRTHDAY _______________________ 

 

Your Health information:                                                                                                          

Have you ever been diagnosed with any of the following?

Staph infection O        Eczema O        Psoriasis  O      Skin Cancer O

Rosacea O       Herpes O    High blood pressure O     Diabetes    O

Thyroid   O       HIV/AIDS  O     Hormonal issues    O        PCOS    O

 

Are you currently taking any medications affecting your skin?

Have you ever been prescribed Accutane®       when?  

Have you ever been prescribed RetinA®      Renova                Differin            or Tazorac         when?

Are you prone to hyper pigmentation?

Are you prone to scarring?

Do you have any product allergies?

Have you recently had

dermabrasion  O        chemical peel  O     facial with extractions  O

laser  O     microneedling   O  tanning  O

Do you 

smoke  O                   use recreational drugs   O     use fabric softeners     O

swim in chlorinated pool   O   work around chemicals   O

have lot of stress  O

have product allergies    O     Name:

Do you use contraceptive pill    O     IUD  O      Name:

Your Skin Information:

Sensitive     O       Dry/ Itchy/ rough touch  O            Reactive/diffuse redness    O   

Dry/ Feeling tight  O           Oily     O                 Combination      O                             

 

What are your present skincare concerns?

Acne cysts    O            inflamed red pimples    O            Blackheads      O         Acne Scars    O          Whiteheads        O                       Enlarged Pores      O          Dehydrated   O           Dilated Capillaries    O                 Diffuse redness        O       Hyper-pigmentation  O        Loss of Elasticity    O           Wrinkling   O

 

Other Concern

Eyes:      Crows Feet/Wrinkles  O      Puffiness        O              Dark Circles   O

Mouth:   Vertical lines      O               Chapped lips  O

Body:      Dry skin     O            Cellulite     O              Lack of firmness  O

Ingrown hair     O          

Neck & Décolleté Area:        Wrinkles  O                  Lack of Elasticity      O         Severe Sun Damage    O

                       

When exposed to the sun, do you?

 Always burn  O      Burn Easily   O      Sometimes burn, tan easily  O

Always tan   O        Never Burn   O        Dark skin    O

 

Your Home Routine:                                                               Am             Pm                                         Product Brand                        

Cleanser                                                                                  O                  O

Circle type of cleanser: soap / foaming gel / milk   oil  / micellar water  / none

 

Toner                                                                                       O                   O

Moisturizer                                                                              O                     O

Serum                                                                                     O                     O

Facial scrub                                                                             O                    O

Sunscreen                                                                                O                   O

Body lotion                                                                               O                   O

Acne med                                                                                O                    O

Makeup                                                                                   O                   O

 

I understand that the advice I have requested may cause an adverse reaction to my skin, body or hair and I agree to release Le French Skincare and its agents from any and all damage or injury that may result from the advice I have requested.

Signature:                                                                               Date: