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SqueezeSkin Regimen Review
Tell us about your skin health and current regimen and we will help you fill in the gaps. We’ll carefully review and analyze this information to create your perfect skincare regimen!
Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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5
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31
Day
Please select a year
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
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1992
1991
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1961
1960
1959
1958
1957
1956
1955
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1953
1952
Year
E-mail
*
Where can we email your regimen?
Phone Number
*
Where can we text you?
Instagram Handle
*
Ex. @theplasticnp
How did you find me?
*
Instagram
Facebook
Search engine (google, yahoo)
Patient Referral
Skin Condition
Describe how your skin feels when you cleanse and let it dry for 20 minutes without applying any products:
*
Tight
Normal
Oily/Shiny
Irritated/ Red
Other
Describe your skin concerns:
*
Acne Prone
Hormonal Acne
Hyperpigmentation/ Dark Spots
Fine Lines
Cystic Acne
Rosacea/ Redness
Hypopigmentation/ Light Spots
Milia
Acne Scarring
Sun Damage
Large Pores
Broken Capillaries
Patchy Dryness
Uneven/Blotchy
Not Sure
How many new pimples/blemishes do you get per month
*
1-2 a month
3-4 a month
2+ every week
How much time a day to you spend exposed to sunlight?
*
Less than 30 minutes (ie limited windows)
More than 30 minutes (ie morning walk)
More than 1 hour (ie commute to work)
More than 2 hours (ei outdoor sports)
How often do you wear foundation makeup?
*
occasionally on weekends
3-4 times a week
5 days a week
7 days a week
What is your primary motivation to wear makeup?
*
Cover redness
Cover Acne
Cover Dark spots
Contour and sculpt
Have you ever been told you have melasma?
*
Yes
No
Are you currently under the care of a Dermatologist?
*
Yes
No
Pending Appointment
Are you using any prescription medication/ RX topicals that you apply to you face?
*
Yes
No
If so, please list them:
List name, strength, dose and frequency of use.
Have you ever been told you have eczema on your face?
*
Yes
No
Please list your morning skincare products:
*
List in order of application
Do you reapply your sunscreen throughout the day?
*
No
Brush-on or Powder Sunscreen
Spray Sunscreen
Cream Compact Sunscreen
Other
Please list your evening skincare products:
*
List your PM skincare in order of application
Are you currently using any skincare products that contain active ingredients (Glycolic/Salicylic Acid, Retinoids/Vitamin A)?
*
Yes
No
Has any skincare product ever caused a bad reaction?
*
Yes
No
Have you ever had a sensitivity to medical grade or highly concentrated vitamin C?
*
Yes
No
If so, what skincare product and describe reaction:
Describe ingredient allergies, breakouts, rashes, etc
Cosmetic Procedures
What cosmetic procedures do you receive throughout the year?
*
Microneedling
Dermaplaning
Chemical Peels
Microdermabrasion
Laser
Photofacials/ IPL/ BBL
Facials/ Hydrafacials/ Extractions
None
Other
Neuromodulators
Botox, Dysport, Xeomin, Daxi
Do you currently have any of the following static lines?
*
Forehead Wrinkles
Frown Lines
Bunny Lines
Crow's Feet
Nasolabial Folds (nose to mouth lines)
Vertical Lip Lines (smoker’s lines)
Marionette Lines (concerns of mouth to jaw)
None
Fillers
Restylane, Juvederm, RHA, Versa, Radiesse, Bellafill, Artefill
Have you ever been treated with any of the following?
*
Hyaluronic Acid Dermal Filler (Juvederm, Restylane, Versa, RHA)
Calcium Hydroxyapatite (Radiesse)
Sculptra (PLLA)
Silicone Injections
Bellafill
Artefill
Other
Other:
Biostimulators
Sculptra, PRP, PRF, EzGel/Biofiller, Exosomes
Have you ever been treated with any of the following?
*
Sculptra (PLLA)
Hyperdilute Radiesse (CaHA)
PRP
PRF
PRF EzGel or BioFiller
Exosomes
No
Other
If so, when and what areas?
Take a Photo
Please stand in front of a window and take two photos without any makeup, filters or facial expression.
Facing the camera (Anterior)
*
Looking to the side (Profile)
*
Cosmetic Goals & Outcomes
Describe your primary concerns:
*
Describe the outcome you would like to achieve from your skincare regimen:
*
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