| Name:: |
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| Street:: |
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| City, State & Zip:: |
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| Daytime Telephone No.: |
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| Alternate Telephone No.: |
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| E-mail:: |
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| What skin care problem do you need help with ?: |
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| Do you need help determing skin type ?: |
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| Do you need help determining skin condition: |
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| Do you use the same soap on your face as your body ?: |
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| Are you male or female ?: |
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| What is your ethnicity ?: |
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| What is your age ?: |
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| How many times you cleanse your face ?: |
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| Do you use tonors, astringents, tonics?: |
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| Do you use a sunscreen daily on your face ?: |
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| Do you use moisturizers on your face ?: |
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| Do you use masques or scrubs ?: |
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| Are you using a topical medication prescribed by your doctor on your face ?: |
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| What cleanser do you cleanse your skin with ?: |
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| Are you pregnant ?: |
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| Do you take medications for hypertension, diabetes, cholesterol, hormones ?: |
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| Any health conditions ?: |
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| Do you have any uneven skin tone ? dark marks ?: |
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| Do you have acne and dry skin ?: |
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| Do you have acne and oily skin ?: |
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| Do you have allergies ? |
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| Do you have exema on your face ?: |
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| Do you consume caffeine, tea, chocolate ?: |
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| How much water do you drink daily ?: |
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| Do you daily eat meat and/or dairy products ?: |
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| Do your exercise regularly ?: |
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| Is your skin type Dry, Oily, Combination, Normal?: |
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| What are your Skin Conditions ? Mature, Sensitive, Oily/Asphyxiated, Acneic, Uneven ?: |
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