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Dermalogica Consultation Form

Personal Details

First Name
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Last Name
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Address 1
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Address 2
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City
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Country
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Telephone Number
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Email Address(*)
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Age
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Your Health

Within the last year, have you been under a dermatologist or other physicians care?
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Witin the last 9 monts, have you undergone surgery?
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If Yes, Please Specify
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Have you had any of these health problems in the past or present?
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List Medications, Supplements, Vitamins, Diuetics, Slimming Tablets etc that you take regularly
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Do You Smoke?
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Do You Exercise Regularly?
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Do You Follow a restricted diet?
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Do You Wear Contact Lenses?
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Your Skin

Do you have any special skin problems pertaining to your face and body?
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If yes, please specify
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What skincare products are you currently using on your face?
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What products are you currently using on your body?
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Exfoliation History

Do you use Accutane, Renova, Adapalene or any other proescribed skin products?
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In the last month?
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Are you currently using any products that contain the following ingredients?
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Moisture Hydration

How much plain water do you consume daily?
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How many alcoholic beverages do you consume weekly?
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Do you ever experience these conditions on your skin?
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What SPF Sunscreen do you use on your face?
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What SPF Sunscreen do you use on your body?
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Do you sunbathe or use tanning beds?
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Capillary Activity

Do You Burn Easily in moderate sunlight?
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Do you blush easily when nervous?
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Do you have a tendency to have high redness?
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Do you suffer from sinus problems?
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Oil Secretion

Do you ever experience oily shine during the day?
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Do you ever experience skin breakouts?
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Nerve Activity

Do you drink more than 4 caffeinated beverages daily? (Coffee, Tea, Soft Drinks)
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Do you ever experience burning, itching sensation on your skin?
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Have you ever had a reaction to any of the following?
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Other (Female Clients Only)

Do you have any additional breakouts at certain times of the month?
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Are You Pregnant or Breastfeeding?
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Zones 1, 2 & 3 - Choose Your Forehead Condition
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Zones 6 & 8 - choose your eye condition
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Zones 5 & 9 - choose your cheek condition
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Zone 7 - Choose Your Nose Condition
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Zones 11, 12 & 13 - Choose Your chin condition
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Please upload a photo of your face without makeup/tan
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CAPTCHA Anti-Spam(*)
CAPTCHA Anti-Spam
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Submit Form

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Bella Beauty Ballina
6 Harbour Units
Quay Road
Ballina
Co. Mayo
 
T: 096 - 77391

Opening Hours

Monday - Closed

Tuesday - 9.00am - 6.00pm

Wednesday - 9.00am - 6.00pm

Thursday - 9.00am - 9.00pm

Friday - 9.00am - 9.00pm

Saturday - 9.00am - 5.00pm

Sunday - Closed