Please complete the form below for a FREE online consultation with our Skin Care Therapist to help you decide which Dermalogica products are best suited for you. All information will be handled with complete confidentiality.

First Name

Last Name

Address1

Address2

City

Province

Postal Code

Telephone Number

Email Address

Age *

Under 2121-3031-4041-5051-6060+

YOUR HEALTH...

Within the last year, have

you been under dermatologist or physician's care?

YesNo

Within the last 9 months,

have you undergone surgery?

YesNo

If yes, please specify

Have you had any of

these health problems in the past or present?

YesNo

List medications,

supplements, vitamins,

diuretics, etc. that you take regularly

Do you smoke?

YesNo

Do you exercise regularly?

YesNo

Do you follow a restricted diet?

YesNo

Do you wear contact lenses?

YesNo

YOUR SKIN...

Do you have any special

skin problems pertaining to your face and body?

YesNo

If yes, please specify

What skin care products are you currently using?

Face

SoapCleanserTonerMoisturizerMasqueExfoliatorEye Products

Body

SoapShower GelScrubsOilBody MoisturizerDepilatory ProductsSelf Tanners

EXFOLIATION HISTORY...

Do you use Accutane,

Retin A, Renova,

Adapalene or any other presciption skin products?

YesNo

In the last month?

YesNo

Are you currently

using any

products that contain the following ingredients?

Glycolic AcidLactic AcidAny Exfoliating ScrubsAny Hydroxy Acid ProductVitamin A Derivatives (i.e. retinol)

MOISTURE HYDRATION...

How much plain water do you consume daily?

How many alcoholic

beverages do you consume weekly?

Do you ever

experience these conditions on your skin?

FlakinessTightnessObvious Dryness

What SPF sunscreen do you use on your...

Face

Body

Do you sunbathe or use tanning beds?

YesNo

CAPILLARY ACTIVITY...

Do you burn easily in moderate sunlight?

YesNo

Do you have a tendency to redness?

YesNo

Do you suffer from sinus problems?

YesNo

OIL SECRETION...

Do you ever experience oily shine during the day?

YesNoOccasionally

Do you ever experience skin breakouts?

YesNoOccasionally

NERVE ACTIVITY...

Do you drink more

than 4 caffeinated

beverages daily (coffee, tea, soft drinks)?

YesNo

Do you ever

experience burning,

itching sensation on your skin?

YesNo

Have you ever

had a reaction to any of the following?

CosmeticsMedicineIodinePollenFoodHydroxy AcidsAnimalsFragranceSunscreens

Other

QUESTIONS TO DISCUSS EVERY VISIT...

What are your skin care goals?

 

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