elénzia GOLD™ Consultation Form Welcome to your elénzia GOLD™ Consultation Form Name Email Company Phone What are your skincare goals? What are your skin care challenges? Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity Other - Please specify Have you previously had facial or skin treatments? No Yes - Please specify Do you use any vitamin A derivatives? Including: Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol etc. No Yes, but not within the last 6 month Yes, but not within the last 30 days Yes, currently (please specify) Have you previously had a chemical peel, laser service or microdermabrasion treatment? No Yes, within the last 2-3 months Yes, within the last 30 days Have you had any dermal fillers or anti-wrinkle injections in the last two weeks? Including: Botox, Juvaderm, Restylane etc. No Yes Have you had any facial hair removal treatments in the last 30 days? Waxing Sugaring Threading Electrolysis / Laser Shaving None What skincare products do you currently use? Select all that apply. If you are seeking corrective treatments please detail the specific brand/products below. Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Products Lip Products What would you grade your cellulite? 0 - I don't have cellulite 1 - Smooth with minor dimples when sitting 2 - Moderate dimples (sitting and standing) 3 - Severe dimples (sitting and standing) Are you wanting to contour your figure? No Yes Which are your areas of concern? Arms Thighs Buttocks Stomach Have you had any body hair removal treatments in the last 30 days? Waxing Sugaring Threading Electrolysis / Laser Shaving None Time is Up! Time's up
