Skin Care Form

Skin Care Intake Form
I am interested in:
Do you have any of the following conditions? If yes, please select them:
Skin Types/Conditions (check all that apply)
How does your skin heal?
How does your skin respond to the sun?
Do you consume caffeinated drinks?
Do you drink alcohol regularly?
Are you currently following any kind of diet?
Do you have digestive issues?
Do you have any allergies? If so, what?
Are you pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptive pills?
Are you breastfeeding?
Are you on hormone replacement therapy?
Do you smoke?
Are you working with a dermatologist?

Terms & Conditions

I understand that my data will be strictly confidential. Lotus Evolutions’ spa studio does not sell, share, or resell information.

I confirm that all information in this form is true and accurate for the benefit of my health and to get the most benefit from my future treatments. Withheld information is not the fault of Lotus Evolution and we will not be liable for false statements.