EmailMeForm
Planet Beauty Consultation Form
Please answer these questions to help us provide the best service for your skin.
Your Details
Name
*
Address
Street Address
City
State / Province / Region
Postal / Zip Code
Email
*
Phone
*
How did you hear about us?
Your Health:
1/ Within the last year, have you had any health problems that have affected or could affect your skin?
Yes
No
If yes, please specify:
2/ List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin etc, that you take regularly.
3/ Do you have any allergies?
Yes
No
If yes, please specify:
Your Skin:
4/ What are your specific concerns/challenges with your skin?
5/ What skin products are you currently using?
Soap
Cleanser
Toner
Moisturiser
Masque
Exfoliant
Eye Products
Other
6/ Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Other Hydroxy acids
Any exfoliating scrubs
Vitamin A derivatives (eg Retinol)
7/ Please specify if any of the following apply to you.
Pregnant
Trying to become pregnant
Lactating
Menstruating
Pre-menstrual
This consultation form is used to evaluate your individual skincare needs. We will maintain the confidentiality of this information and will disclose this information only: a) to our staff members, b) quality assurance and quality control personnel, c) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.
I confirm (to the best of my 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
No
