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Welcome
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Personal information
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
Email
*
Phone
*
About your health
Do you know which is your skin type?
Yes
No
Skin type
Oiliness
Acne - inflammations
Cystic acne
Dry
Normal - mixed
Dehydrated
Sensitive
Skin with Hyperpigmentation
Vascular vessels
Wrinkles
Relaxation
Have you had clinical diagnosis about your skin type?
Yes
No
Have you had any surgery in the last 9 months?
*
Yes
No
Please explain
*
Have you had any health problems in the past or in the present?
*
Yes
No
(Cancer, malignancy, diabetes, epilepsy, cardio-logical problems, hormonal disorders)
Please explain
*
Do you homeopathy?
*
Yes
No
Do you have metal parts on your body, or pacemaker?
*
Yes
No
Do you take any medicines?
*
Yes
No
Do you have any allergies?
*
Yes
No
especially in Salicylic Acid?
Do you often get herpes or choroid?
*
Yes
No
Are you claustrophobic?
*
Yes
No
Do you smoke?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Have you noticed any rush or any kind of reaction to any of the below?
Cosmetics
Pollen
Medicines
Hydroxy acids
About your skin
Do you have any specific skin problem on your face or body?
*
Yes
No
Please explain
Does your skin look very oily during the day?
*
Yes
No
Have you noticed any rush on your body or face?
*
Yes
No
Do you feel your skin dry?
*
Yes
No
What do you usually do for your daily care?
Cleanser
Tonic
Moisturizing cream
Mask
Peeling
Eye cream
I also do a daily care for my body
Body daily care, please explain
Have you ever had a chemical peel or Dermabrassion?
*
Yes
No
Have you ever done a healing program on your face or body in the last year?
*
Yes
No
Please explain
Do you epllate your face or body?
*
Face
Body
Do you get tan or sunburn?
Tan
Sunburn
Do you get sunbath or solarium
Sunbath
Solarium
How much water do you drink per day?
*
Less than 1lt.
1lt. or 2 lt.
More than 2lt.
Final questions
Please select
*
Ladies
Gentlemen
Is your period stable?
*
Yes
No
Do you take contraception peels?
*
Yes
No
Are you pregnant or trying to be?
*
Yes
No
Breastfeeding?
*
Yes
No
Are you in premenopausal?
Yes
No
How do you usually shave?
*
Do you get a rush after shaving?
*
Yes
No
Have you noticed any hair that grow internally on your skin?
*
Yes
No
If there are specific improvements you are seeking for your body or face, please let us know.
Treatment and skin plan
I don't have a treatment plan yet
I have been informed in detail about the treatment process and how I should take care of my skin in the up-coming days.
Email
This field is for validation purposes and should be left unchanged.
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