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Skin Consultation Form - Lumilaser Advanced Esthetics
Please ensure you fill-out the form below for your online skin consultation.
Skin Consultation Form
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Email
*
Phone Number
*
1) What are your main skin concerns?
*
2) Are you struggling with acne, scars, facial redness, rosacea on your face?
*
3) Are you currently under the care of a doctor and or dermatologist? What is his/her name?
*
4) Do you have any health problems or medical conditions?
*
5) Please list all medications you are currently taking including topical prescriptions.
*
6) Do you have any known allergies (including food and seasonal)?
*
7) Please describe your skincare routine, what products are you currently using?
*
8) How do you feel with the products you are currently using?
*
9) Have you experienced sensitivity from any skincare products?
*
10) At the END of the day, how does your face/skin feels?
*
Oily all over
Shiny T-Zone
Dry Cheeks
Dry all over
Skin is itchy and tight
Other comments
*
Upload photos or video of your skin, face
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
I consent to uploading photos and videos of my face, skin. I consent to my photos being used for office use, assessing progress, comparing results, as well for educational, training and advertising purposes. At all times, my identity will remain strictly confidential and my eyes will be covered, protected, when photos are being published on Lumilaser's website or social medias.
*
Yes
No
Digital Signature and Full Disclosure
CLIENT DIGITAL SIGNATURE & FULL DISCLOSURE AGREEMENT : I understand, I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from the suggested products and protocol to follow. The skincare advice and product suggestions that I receive from Eve Mamane, Lumilaser Advanced Esthetics are voluntary, and I release this institution and/or skincare professional from liability and assume full responsibility thereof.
*
** I agree **
Submit
Home
Services
Acne
Facials
Dermaplaning
MicroInfusion
Microdermabrasion
PhotoRejuvenation
Skin Brightening
Pigmentation
Couperose
Tele-Skincare
Epilation Laser Hair Removal
Detatouage - Tattoo Removal
Vergetures - Stretch Marks - Scars
Cils - Lash Lift
Shop
Contact
A Propos - About Us
Produits - Products
Aquafolia
>
Anti-Acne
Casmara Masks
Clayton Shagal
Eltraderm
iS Clinical
>
Nettoyants - Cleansers
Exfoliants
Serums
Hydratants - Moisturizers
Yeux - Eye Care
Lèvres - Lip Care
South Beach Skin
Tizo
Avis - Reviews
Promotions
COVID-19
Blog