Please fill out this consultation form so we can send you the right products!
After we review your consultation form and receive payment, your products will be sent!
Always, let us know if you have any questions or if your skin is getting too dry or irritated.

Consultation Form

It is important that we send you the right products that will benefit your skin.  This consultation form helps us help you choose the right products and will alert us if there is a contraindication for you using a product.
Are you a student? What grade:*
Are you currently under a lot of stress?*
Women: Do you use birthcontrol pills, shots or use an IUD? If yes, what brand*
Men: Do you have irritation shaving? If Yes, what type of razor do you use for shaving?*
Diet: Have you consumed any of the following in the past week?*
Skincare Products you are currently using: Please provide product names*
Medical History (check all that apply)*
Are you currently under a Dermatologist care?*
List any prescription medications you've been on with a Dermatologist *
Have you ever had any reaction to any products or anything you have put on your face?*
If yes, what products?*
Are you allergic to any of the following?*
If you checked "other", what allergies do you have?*
Do you smoke?*
Do you use fabric softener?*
Do you swim in a chlorinated pool?*
Do you work around chemicals, tars, oils, grease or inks?*
Do you work nights?*
Please check any procedure you've done in the past 6 months:*
Have you ever taken antibiotics for your acne? *
If Yes, Please list the dates*
Have you ever taken Birth Control for your acne?*
If yes, Please list the name of the birth control and the dates you've used it*
Have you ever taken Accutane (or other name brand of Accutane)?*
If yes, please list the dates you have taken accutane and the %*
Please check any of these medications that you've taken in the past 12 months*
Does your skin feel dry, irritated or stinging with your current products?*
What areas do you feel are your most problematic?*
Is there anything else you would like us to know so that we can better help you achieve clear skin?