Customer Application Form - Aesthetica Skin Centre

Customer Application Form

Choose your Age Group
What type of skin do you have?
Normal Oily Dry Combination
Have you ever had an allergic reaction to any of the following?
Cosmetics Medicine Alpha Hydroxy Acid (AHA) Animals Sunscreen Iodine Shellfish
Are you currently Pregnant or Breastfeeding?
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
Do you currently smoke?
Do you use a Cleanser?
Do you use a Toner?
Do you use a Serum?
Do you use a Moisturizer?
Do you use a Sun Screen?
What conditions would you like to improve about your skin? (Select all that apply)
Acne Fine Lines/Wrinkles Uneven Tone/Texture Enlarged Pores
Age Spots/Freckles Hormonal Pigmentation Dark Under Eye Circles
Saggy Skin Oily Skin Dehydration Redness/Eczema