Loading... Please wait...

Popular Brands

Offers & Promotions


Dermalogica Consultation Form

First Name:
Last Name:
*Your Email Address:
Mobile:
*Age-Range:
Do you currently have any medical conditions?:



Details of Current Medical Conditions:
List any medications, supplements, vitamins etc. that you take regularly:
Have you had any recent surgery ? (last 9 months):



Recent Surgery Details:
Do you smoke?:



Do you exercise regularly?:



Do you follow a restricted diet?:



Rate your level of stress:
Do you have any special skin problems pertaining to your face or body?:



Skin Problem Details:
What skin care products are you currently using on your Face (Select all that apply):













What skin care products are you currently using on your Body (Select all that apply):













Have you ever had chemical peels, microdermabrasion or any resurfacing treatments?:


Do you use Accutane, Retin-A, Renova, Adapalene or other prescription skin products?:



Are you currently using any products that contain the following ingredients?:









How much plain water do you consume daily:
How many alcoholic beverages do you consume weekly?:
Do you ever experience these conditions on your skin?:





What SPF Sunscreen do you use on your face?:
What SPF Sunscreen do you use on your body?:
Do you sunbathe or use sunbeds?:



Do you burn easily in moderate sunlight?:



Do you blush easily when nervous?:



Do you have a tendency to redness?:



Do you suffer from sinus problems?:



Do you ever experience oily shine during the day?:





Do you ever experience skin breakouts?:





Do you drink more than 4 caffeinated beverages daily?:



Do you ever experience a burning, itching sensation on your skin?:



Have you ever had a reaction to any of the following?:

















(Females only) Are you pregnant or trying to become pregnant?:



(Males only) What is is your current shaving system?:



(Males only) Do you experience irritation from shaving?:





(Males only) Do you experience ingrown hairs?:





What are your skin care goals?:
*  Enter the security code shown: