Monday & Tuesday 9:00am – 5:00pm
Wednesday 9:00am – 7:00pm
Thursday & Friday 9:00am – 5:00pm
Saturday & Sunday Closed
1170 Dolphin st White Rock, BC, Canada V4B 4G8
Postal Code / Zip:
Date of Birth (click to set a date):
Address Line 2:
Province / State:
* Please mention when and for how long in each applicable field:
Retin A Cream / Gel
Other? Please specify:
What supplements are you currently taking?*
Blush / Bronzer*
Exfoliant (ex. Glycolic)*
When did you use each of these products?* (ie - Month/Year/How long)
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?
If yes, describe:
Check if you are allergic to:*
Do you smoke?
At what age did your acne start?
Do you use fabric softener or fabric softener sheets in the dryer?
Do you pick at your skin?
Do you work around chemicals, tars, oils or inks?
Are you currently under a lot of stress?
Do you swim in chlorinated pools?*
Do you regularly ingest:
Women only: Are you on birth control pills or IUD?*
If so, which brand?
Are you taking Depo Provera shots?
Are you pregnant or nursing?
What are your skin care concerns?:*
BlackheadsDehydrated SkinDry/Flaky SkinOilyWhiteheadsDark SpotsSensitive SkinNormalPimples/PustulesAge SpotsRazor BumpsDryCystsBroken CapillariesShaving IrritationOily/DryOily SkinFine Lines/WrinklesAcne RosaceaSensitiveNone
Have you done the following treatments before?*
Glycolic Acid PeelsMicrodermabrasionChemical PeelsSkin Cancer RemovalPlastic SurgeryLaser Hair RemovalFacial WaxingElectrolysisOtherNone
If so, please explain:
Medical History: Check any condition you may have had in the past two years:*
DiabetesHepatitisHemophiliaThyroid ProblemsHIV + or AIDSThrombosis/BloodClot/StrokeEczemaStaph Infection or MRSAMetal pins or brackets in bodyPsoriasisHormone ProblemsPacemakerPregnancyHerpes Simplex/Cold SoresHysterectomy/ovaries removedNursingHigh Blood PressurePCOSCancerAnemiaLupusNone
Are you under a Dermatologist’s Care?
What kind of work do you do?*
How did you hear about us?*
What results would you like to obtain with your skin?*
Please submit 3 photos of your skin: left side, right side and straight on.
*Please take skin photos in natural light. (Facing a window is best.)
**Please don't use direct sunlight or synthetic light (these create shadows).
( Ctrl + Click to select multiple photos )