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) Please describe your makeup routine - if applicable *

10) Have you experienced sensitivity from any skincare products? *

11) At the END of the day, how does your face/skin feels? *

Other comments *

12) Please describe your work environment *

13) Rate your current stress level on the scale of 1-10 (10 being the highest level) *

14) What are your sports and leisure activities? *

15) Are you pregnant? (Women only) *

Upload photos and or videos of your skin, face

Upload File *

Max file size: 20MB

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