Biologique Recherche Skincare Consultation

Email

Phone Number

Age

Preferred Method of Contact *

Email

Phone

What do you wish to achieve with your skin? *

Please check (if applicable)

Bee Allergy

Latex Allergy

Nut Allergy

Other Allergy

Please specify if Other Allergy...

Current Skincare Product Usage

Please specify whether you use the product, the brand of product, the type of product, and how often you use the product.

Cleanser *

Toner / Astringent *

Day Moisturizer *

Night Moisturizer *

Mask *

Exfoliating Scrub *

Eye Cream *

Retin A *

AHA / Glycolic *

Topical Prescription *

Describe any reaction to any skin care product / cosmetic or skin care treatment experienced within the last 24 months.

Have you taken or are currently taking Accutane or a prescription topical acne cream? *

Have you ever used AHA's (Alpha Hydroxy Acid)/Glycolics? *

Are you pregnant? *

Yes

No

Are you breast feeding? *

Yes

No

Do you sunbathe outdoors or tanning beds? *

Never

Rarely

Often

Do you smoke? *

Yes

No

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Skincare Consultation