1. Name: (required)              

 2. Email Address: (required)  

 3. Address:   City  State Zip

 4. Phone Number:   Best time to reach you? Time Morning Daytime Afternoon Evening

 5. What are your biggest concerns regarding your skin (check all that apply)?

 6. How would you best describe your skin (check all that apply)?

 7. What products do you wash with?

 8. What moisturizer do you use?

 9. Question?

10. Do you spent a lot of time outdoors? Yes No

11. Do you wear sunscreen? Always Sometimes Never

12. Do you go to tanning booths? Frequently Sometimes Never

13. Do you smoke? Yes No

14. Are you currently using Retin-A or Renova? Yes No

15. If so, how long have you been using it?
under 3 months 3 months-1 year 1-3 years over 3 years

16. Do you experience any irritation, dryness or flakiness from Retin-A?
Yes No

17. Are you currently using the drug Accutane? Yes No

18. Have you undergone laser skin resurfacing in the last 3 months?
Yes No

19. Do you have allergies to any of the following?
Alpha-hydroxy acids Hydroquinone Preservatives Fragrances

20. List any other known allergies: (optional)

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:

This questionnaire submitted online, by mail or fax, is not a substitute for an in-person consultation with a licensed esthetician or doctor. Esthetics by Alison analyzes your skin type and suggest products based on the completeness and accuracy of the information provided by you. Please use our fax number: (941) 388-7015.

All products are 100% guaranteed by Esthetics by Alison. If for any reason you're not 100% satisfied with any item, we will refund the purchase price of the products. Simply return the products with the original sales receipt to Esthetics by Alison. We must receive your return within 30 days of purchase for a full product refund and tax (less shipping and handling, if applicable).

To return, replace or exchange any product call us at (941) 544-4868