Consultation Form

Contact Information

Name:

Address:

City:

State:

Zip Code:

Your Email Address:

What is the best number to reach you?

How Did You Hear About Us?

Skin Health Information

1. Your Age is:

2. Your Sex is: FemaleMale

3. Do you smoke? YesNo

4. Do You Have Allergies to Any Of The Following? (Check all that apply) AspirinHydroquinoneSalicyclic AcidRetin-AHydrogen PeroxideBeta HydroxyacidsNo allergies to any of the above

5. Do you currently take any antioxidant supplements? YesNo

6. Do you use Retin-A? YesNo

7. Have you ever used the Acne drug Acutane? YesNo

8. Do you have any special skin problems? (Check all that apply)I have adolescent Acne eruptionsI have deep cystic AcneI have dry skin with Acne breakoutsI have combination skin, dry in some places, oily in the T zoneI have smooth, normal skinI have lines and wrinkles from natural agingI have no special skin problems

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. The estheticians of Oxygen Medical Spa’s Skin Health Experts® analyze your skin type and suggest products solely on the completeness and accuracy of the information provided by you. You will receive a personalized E-Mail response from one of our Skin Health Experts within 24 hours of sending your inquiry. If you require an immediate response, please call our toll free number at 1-800-998-5989 Monday-Saturday between 7:30 AM and 6:30 PM and one of Oxygen Medical Spa’s Skin Health Experts will be happy to assist you.