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Book an Expert Skincare Consultation

Skin Assessment with EYS
We're here to help you reach your healthy skin goals
Service Information
30 US dollars

Client Intake Form-Facial

Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

Birthday

Have you ever had a facial?

Yes

What is your main concern with your skin?

Are you presently under a physician's care for any current skin condition or other problem?

If yes, please explain

Are you pregnant?

Are you taking birth control pills?, If "Yes", what type?

Are you presently using (or used in the past) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or AHA's?

Are you now using or have you ever used Accutane?

Are you presently taking any medications

Do you smoke?

Do you have any allergies to cosmetics, ingredinents, foods or drugs?

Have you had skin cancer?

Do you often experience stress?

What skin care products do you use presently?

Upload File

Upload supported file (Max 15MB)

Please check if you are affected by or have any of the follwing:

Headaches-Chronic

Asthma

Depression

Herpes

Fever Blisters

Anxiety

Epilepsy

Hysterectomy

Skin Disease

Hepatitis

High Blood Pressure

Sinus Problems

Immune Disorders

Hair Loss

Eczema

Metal bones, pins or plates

Plastic Surgery

Botox

Please explain above problems or list any other significant issues.

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

CONTACT US

13101 W Washington Blvd, Los Angeles, Ca 90066

| Tel: 800-839-7991

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Book an Expert Skincare Consultation

Skin Assessment with EYS

Client Intake Form-Facial

Submissions are valid up to 24 hours prior to the activity.

CONTACT US