Print this form and prepare for your detailed complimentary skin care consultation with your purchase.

This form may be sent by email to:

consult@faceassets.com.

Or this form can be reviewed by phone at:

877-607-5670:

(9:00 am to 5:00 pm, MST).

You can arrange an appointment time for this consultation so as to give the consultation the appropriate attention to detail for your best results and care direction. Arrange this appointment by contacting us by email: consult@faceassets.com or by calling us to arrange the time at 877-607-5670.

Without product purchase this consultation will have a fee for service of $25.00 for the consultation time. You will be asked for your credit card at the beginning of the interview to prepare your personal information.

You will be asked for discount rewards codes and coupons codes at the beginning of your consultation, so please have them handy.

Current Customers May Shop Now! http://www.shop.faceassets.com

Face Assets, LLC
877-607- 5670

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CONSULT NOW

Face Assets, LLC On-Line Consultation Form

Personal Information

It is very important that you give us the best contact method and best time to reach you and complete your consultation. You may also call 877-607-5670 9 AM to 5 PM MST to discuss this form and the consultation time.

Date *

First Name: *

Last Name: *

What is the best way to contact you? (Phone or Email): *

Email Address:*

Daytime Phone Number: *

Age: *

Address Street

Suite / Apt.

City: *

Zip Code:

State:

Skin Typing Information

Hair Color:(Blond, Red, Brown, Light Brown, Dark Brown, Black, Grey)
*

Eye Color:
(Blue, Green, Hazel, Brown, Black)
*

Skin Tone: (Pink, Peach, Olive, Native American, Hispanic, Asian, Black)
*

What type of skin do you feel that you have right now?: Normal Oily Dry Combination
*

Medical History- Your skin is your body's largest organ. Your medical history, medications and a good skin specific medical history is important to pick the best ingredients for your personal skin care

Pleast list any health conditions you may have: Claustrophobia, Diabetis, Epilepsy, Heart Disease, High or Low Blood Presure?:

Pacemaker? Y/N

Herpetic Breakouts? Y/N

Cold Sores? Y/N

Frequent Sinus Infections? Y/N

Immune Deficiences? Y/N (Lupus, AIDS / HIV)

Are You Pregnant or Lactating? Y/N

Do you have any allergies?
(List Medicines and environmental)

Complexion Concerns? Y/N

Acne? Y/N

Acne Where?

Whiteheads? Y/N

Rosacea? Y/N

Eczema? Y/N

Psoriasis? Y/N

Wrinkles? Y/N

Age Spots on Hands?
Y/N

Hyperpigmentation?
Y/N

Hypopigmentation?
Y/N

Broken Capillaries?
Y/N

Warts? Y/N

Dry Scalp? Y/N

Dehydration (dry skin)? Y/N

Cellulite? Y/N

Have you had Facials from an Esthetician? Y/N

Glycolic Peels? Y/N

Salicylic Peels? Y/N

Microdermabrasion?
Y/N

Jesners's Peel ? Y/N

Bodywraps? Y/N

Massage? Y/N

Edermologies?

Lash or Eye Brow Tint? Y/N

Make-Overs? Y/N

TCA Peels? Y/N

Medical Microdermabrason? Y/N

CO2 Laser? Y/N

IPL? Y/N

Fraxel? Y/N

Laser Tightenting Procedure? Y/N

Waxing? Y/N

Laser hair Removal? Y/N

If you have had Laser Hair Removal--- Where?

Have you had any complications from the above?

        If so please
        describe the
        complications.

List All Medications in the blocks here and below:

Any Topical Medications?( including Retin-A and AHA's

Any Surgeries, including Cosmetic
(Please List)

Life Style Information

Stress Test

from 1-10
what is your stress number?

Sleep Test

How many hours of sleep per night?:

Do you take Vitamin or Mineral Suplements?:Y/N

     If so please
    describe the
    Mineral or Vitamin
    Suplements:

How much water do you drink per day?

Do you salt your food? Y/N

How much caffeine per day?

Do you smoke? Y/N

How much milk do you drink per day?

Do you exercise? Y/N

Do you eat peanut butter? Y/N

Alcohol? Y/N

    If you use alcohol
    How much per
    day/ or week?

Are you a vegetarian? Y/N

Do you suffer from PMS? Y/N

Do you eat a lot of fish?:

Have you experienced menopause? Y/N

What skin care product or cosmetics do you use?

Do any of these products include Glycolics or AHA's ?

Your Goals For This Consultation?

What do you hope to achieve from this consultation?

What are your goals from this or any future skin care program?:

Any additional questions or comments you may have in mind?

Please use this space to address any questions you may have that you would like to have your consultation focus on?