Dermalogica

Let's get personal!

Please answer these questions to help us provide the best service for your skin.

Within the last year, have you had any health problems that have affected or could affect your skin? *

Spa Arilena

Exclusive care for you

Name: *

I confirm(to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. *

Yes

Do you wear contact lenses? *

Yes

If yes, please specify:

Do you have any allergies? *

Yes

Phone *

Have you been waxed within the last 72 hours? *

Yes

Please specify if any of the following apply to you: *

pregnant

trying to become pregnant

lactating

menstruating

pre-menstrual

Not applicable

What are your specific concerns/challenges with your skin? *

Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months? *

Yes

List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, etc. that you take regularly. *

Have you ever experienced claustrophobia? *

Yes

Age *

What skin care products are you currently using? Check all that apply. *

soap

cleanser

toner

moisturizer

masque

exfoliant

eye products

other

none

Are you currently using any products that contain the following ingredients? *

Glycolic Acid

Lactic Acid

any exfoliating scrubs

Hydroxy Acids(AHAs,BHAs)

Vitamin A derivatives(i.e.,Retinol)

None

Do you have sinus problems? *

Yes

Email: *

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months? *

Yes

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Dermalogica

104 N Fordham Ave, Aurora, IL 60506, USA

+1(630)251-7666

spaarilena1@gmail.com

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