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FGM IN-DEPTH CONSULTATION
This form is for US residents only. All details are emailed upon completion of this form.
37
Questions
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1
Name
*
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Hi! I'm Hadiyah. And you are?
First Name
Last Name
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2
Nice to meet you {name}! What's your email?
*
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Gmail is preferred for Hangouts but whichever email you check most frequently is fine.
example@example.com
Confirm Email
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3
Where are you located?
*
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Please use your preferred shipping address
Address
Apartment/Suite/Unit #
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
What is your Twitter or Instagram handle?
We follow our clients back!
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5
Have you read our studio policies?
*
This field is required.
YES
NO
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6
Have you ever visited an esthetician?
*
This field is required.
YES
NO
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7
Are you currently under the care of a dermatologist?
*
This field is required.
YES
NO
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8
Let's see that skin!
*
This field is required.
Please upload at least
three
bare face selfies of the FRONT, RIGHT SIDE, and LEFT SIDE of your face. You can also include additional closeups of problem areas if you feel they are necessary. These photos should be well-lit with the light source being in front of your face, not behind or to the side. And the background should not have any distractions. A plain wall is best.
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Select files to upload
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9
What is your PRIMARY skin care concern?
*
This field is required.
Please choose just ONE option from below
Acne
Acne Scarring (boxcar, ice pick, rolling)
Aging (fine lines/wrinkles)
Dark Circles/Under-eye bags
Dryness
Hyperpigmentation from old scars
Oiliness
Redness
Sensitivity
Texture
Uneven skin tone
Acne
Acne Scarring (boxcar, ice pick, rolling)
Aging (fine lines/wrinkles)
Dark Circles/Under-eye bags
Dryness
Hyperpigmentation from old scars
Oiliness
Redness
Sensitivity
Texture
Uneven skin tone
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10
What are your skin care goals?
*
This field is required.
What are you hoping to achieve by working with an esthetician?
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11
Drop your skin care routine
*
This field is required.
Please list as AM and PM. Feel free to be as detailed as possible. Be sure to include your: cleanser, toner, serum(s), moisturizer(s), sunscreen, occlusive(s), masque(s), exfoliant(s), eye products, spot treatments, and anything else you may be putting on your face on a daily or weekly basis.
NOTE: please indicate how long you've been using each product (i.e. 3 months, 2 weeks, etc.)
EXAMPLE:
AM Fairy Glow Mother Magic Milk Cleanser (6 months) Fairy Glow Mother Hydra Cadabra Toner (4 months) First Aid Beauty Ultra Repair Hydrating Serum (6 months) Fairy Glow Mother Glow Mojo Moisturizer (6 months) Flesh Beauty Sunscreen (3 months) PM Fairy Glow Mother Magic Milk Cleanser Neostrata Clarify Cleanser (1 year) Fairy Glow Mother Hydra Cadabra Toner Fairy Glow Mother Majestic No. 8 Serum (6 months)--only use Tues and Thurs A313 Treatment (1 year)--only use Sun and Weds Aquaphor (since birth)--I do not use this on nights I use A313
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12
Do you ever feel any sensations when applying any of the skin care products you listed previously?
*
This field is required.
Sensations include tingling, "stingling", stinging, heat, itchiness, coolness, burning, etc.
YES
NO
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13
Have you ever had a negative or allergic reaction to any skin care products?
*
This field is required.
YES
NO
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14
If yes, which product and what was the reaction?
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15
Are you satisfied with your current skin care routine?
*
This field is required.
YES
NO
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16
What is your PRIMARY concern with the current skin care routine you have?
Feel free to provide as much detail as you feel necessary.
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17
Which of the following medications have you been prescribed and when did you last use them?
*
This field is required.
N/A
< 3 months ago
3-6 months ago
> 6 months ago
In Use
Antibiotics
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Androstendione
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Accutane
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Azelex
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Avita
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Benzoyl Peroxide
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Cleocin-T
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Copaxone
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Corticosteroids
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Cyclosporin
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Danzol
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Differin
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Dilantin/Tegretol
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Disulfuram
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
E-mycin-T
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Gonadotrophin
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Immuran
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Isoniazid
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Lithium
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
Progesterone
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Quinine
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Retin A
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Steroids
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Tazorac
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Row 23, Column 3
Row 23, Column 4
Testosterone
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Row 24, Column 3
Row 24, Column 4
Other Hard/Illegal Drugs
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
Row 25, Column 3
Row 25, Column 4
Antibiotics
Androstendione
Accutane
Azelex
Avita
Benzoyl Peroxide
Cleocin-T
Copaxone
Corticosteroids
Cyclosporin
Danzol
Differin
Dilantin/Tegretol
Disulfuram
E-mycin-T
Gonadotrophin
Immuran
Isoniazid
Lithium
Progesterone
Quinine
Retin A
Steroids
Tazorac
Testosterone
Other Hard/Illegal Drugs
N/A
Row 0, Column 0
< 3 months ago
Row 0, Column 1
3-6 months ago
Row 0, Column 2
> 6 months ago
Row 0, Column 3
In Use
Row 0, Column 4
N/A
Row 1, Column 0
< 3 months ago
Row 1, Column 1
3-6 months ago
Row 1, Column 2
> 6 months ago
Row 1, Column 3
In Use
Row 1, Column 4
N/A
Row 2, Column 0
< 3 months ago
Row 2, Column 1
3-6 months ago
Row 2, Column 2
> 6 months ago
Row 2, Column 3
In Use
Row 2, Column 4
N/A
Row 3, Column 0
< 3 months ago
Row 3, Column 1
3-6 months ago
Row 3, Column 2
> 6 months ago
Row 3, Column 3
In Use
Row 3, Column 4
N/A
Row 4, Column 0
< 3 months ago
Row 4, Column 1
3-6 months ago
Row 4, Column 2
> 6 months ago
Row 4, Column 3
In Use
Row 4, Column 4
N/A
Row 5, Column 0
< 3 months ago
Row 5, Column 1
3-6 months ago
Row 5, Column 2
> 6 months ago
Row 5, Column 3
In Use
Row 5, Column 4
N/A
Row 6, Column 0
< 3 months ago
Row 6, Column 1
3-6 months ago
Row 6, Column 2
> 6 months ago
Row 6, Column 3
In Use
Row 6, Column 4
N/A
Row 7, Column 0
< 3 months ago
Row 7, Column 1
3-6 months ago
Row 7, Column 2
> 6 months ago
Row 7, Column 3
In Use
Row 7, Column 4
N/A
Row 8, Column 0
< 3 months ago
Row 8, Column 1
3-6 months ago
Row 8, Column 2
> 6 months ago
Row 8, Column 3
In Use
Row 8, Column 4
N/A
Row 9, Column 0
< 3 months ago
Row 9, Column 1
3-6 months ago
Row 9, Column 2
> 6 months ago
Row 9, Column 3
In Use
Row 9, Column 4
N/A
Row 10, Column 0
< 3 months ago
Row 10, Column 1
3-6 months ago
Row 10, Column 2
> 6 months ago
Row 10, Column 3
In Use
Row 10, Column 4
N/A
Row 11, Column 0
< 3 months ago
Row 11, Column 1
3-6 months ago
Row 11, Column 2
> 6 months ago
Row 11, Column 3
In Use
Row 11, Column 4
N/A
Row 12, Column 0
< 3 months ago
Row 12, Column 1
3-6 months ago
Row 12, Column 2
> 6 months ago
Row 12, Column 3
In Use
Row 12, Column 4
N/A
Row 13, Column 0
< 3 months ago
Row 13, Column 1
3-6 months ago
Row 13, Column 2
> 6 months ago
Row 13, Column 3
In Use
Row 13, Column 4
N/A
Row 14, Column 0
< 3 months ago
Row 14, Column 1
3-6 months ago
Row 14, Column 2
> 6 months ago
Row 14, Column 3
In Use
Row 14, Column 4
N/A
Row 15, Column 0
< 3 months ago
Row 15, Column 1
3-6 months ago
Row 15, Column 2
> 6 months ago
Row 15, Column 3
In Use
Row 15, Column 4
N/A
Row 16, Column 0
< 3 months ago
Row 16, Column 1
3-6 months ago
Row 16, Column 2
> 6 months ago
Row 16, Column 3
In Use
Row 16, Column 4
N/A
Row 17, Column 0
< 3 months ago
Row 17, Column 1
3-6 months ago
Row 17, Column 2
> 6 months ago
Row 17, Column 3
In Use
Row 17, Column 4
N/A
Row 18, Column 0
< 3 months ago
Row 18, Column 1
3-6 months ago
Row 18, Column 2
> 6 months ago
Row 18, Column 3
In Use
Row 18, Column 4
N/A
Row 19, Column 0
< 3 months ago
Row 19, Column 1
3-6 months ago
Row 19, Column 2
> 6 months ago
Row 19, Column 3
In Use
Row 19, Column 4
N/A
Row 20, Column 0
< 3 months ago
Row 20, Column 1
3-6 months ago
Row 20, Column 2
> 6 months ago
Row 20, Column 3
In Use
Row 20, Column 4
N/A
Row 21, Column 0
< 3 months ago
Row 21, Column 1
3-6 months ago
Row 21, Column 2
> 6 months ago
Row 21, Column 3
In Use
Row 21, Column 4
N/A
Row 22, Column 0
< 3 months ago
Row 22, Column 1
3-6 months ago
Row 22, Column 2
> 6 months ago
Row 22, Column 3
In Use
Row 22, Column 4
N/A
Row 23, Column 0
< 3 months ago
Row 23, Column 1
3-6 months ago
Row 23, Column 2
> 6 months ago
Row 23, Column 3
In Use
Row 23, Column 4
N/A
Row 24, Column 0
< 3 months ago
Row 24, Column 1
3-6 months ago
Row 24, Column 2
> 6 months ago
Row 24, Column 3
In Use
Row 24, Column 4
N/A
Row 25, Column 0
< 3 months ago
Row 25, Column 1
3-6 months ago
Row 25, Column 2
> 6 months ago
Row 25, Column 3
In Use
Row 25, Column 4
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18
Are there any OTHER prescriptions you are taking from a dermatologist or doctor?
*
This field is required.
Yes, birth control counts.
YES
NO
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19
Please list ALL prescription(s) and date prescribed.
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20
Do you have ANY health conditions?
*
This field is required.
Please check yes if you have any autoimmune/respiratory disorders, systemic diseases, or anything that requires you to be under a doctor's supervision.
YES
NO
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21
What condition(s) do you have?
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22
Do you have ANY allergies?
*
This field is required.
YES
NO
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23
What are you allergic to?
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24
Do you eat any of the following on a WEEKLY basis?
*
This field is required.
Please select all that apply
Cheese
Yogurt
Sugar (processed and refined)
Caffeine
Soy/Whey protein
Fast Food
Processed Foods
Salty Snacks
Peanuts/Peanut Byproducts
Sushi/Kimchi
N/A
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25
Do you workout more than 2x per week?
*
This field is required.
YES
NO
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26
Are you currently on any diets for weight loss?
*
This field is required.
YES
NO
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27
What is the name of your diet?
Please provide a link to this diet's description if it is readily available on the internet
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28
Do you have a modified lifestyle diet?
*
This field is required.
Vegan/Vegetarian/Pescatarian/No Red Meats, etc.
YES
NO
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29
Do you take any supplements/vitamins?
*
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YES
NO
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30
Please list the names of ALL supplements/vitamins you are currently taking.
Any workout shakes, immune booster "shots", etc. count
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31
Are you a smoker?
*
This field is required.
Cigarettes, marijuana, or otherwise
YES
NO
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32
Do you drink more than three alcoholic beverages in a week?
*
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YES
NO
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33
Are you currently taking a form of prescription birth control?
*
This field is required.
If you have an IUD, please answer yes
YES
NO
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34
Are you currently undergoing Hormone Replacement Therapy?
*
This field is required.
YES
NO
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35
Are you currently pregnant or trying to become pregnant within the next 3 months?
*
This field is required.
YES
NO
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36
Please rate your stress level
*
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37
I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from suggestions received. I release this business and/or skin care professional from liability and assume full responsibility thereof.
*
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Please check YES below to submit this form
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