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First Name
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How would you describe your skin type?
Oily
Dry
Combination
Sensitive
Normal
Skin Concerns:
Acne/Blemishes
Blackheads/Whiteheads
Enlarged Pores
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Redness/Rosacea
Uneven Skin Tone
Dryness/Dehydration
Oiliness
Sensitivity
Dark Circles under Eyes
Puffiness
Loss of Elasticity/Firmness
Others
Current Skincare Routine
Please list the products you are currently using
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Other
How would you describe your diet?
I eat organic and clean.
I eat fast food and processed meals.
I maintain a balanced diet.
Vegetarian/Vegan.
If yes, how frequently
How many hours of sleep do you get on average per night?
Less than 5 hours
5-6 hours
7-8 hours
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Do you have any of the following medical conditions?
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Are you currently taking any medications or supplements?
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Have you ever had any of the following treatments?
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Chemical Peels
Lasers
Microdermabrasion
Botox/Fillers
If yes, when was your last treatment?
What are your primary skincare goals?
Is there anything else you'd like us to know before your consultation?
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