Please email back with picture of your skin to email@example.com
All your information is confidential and will not be shared.
CELL PHONE _____________________
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
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
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.