Knowing your skin type is the essential key to a balanced skin. Skin types change as we age, so you must have a clear understanding of what is best for your skin type.

A Faces Esthetician will determine your skin type and tailor a custom beauty prescription to help you select the products that are appropriate for you. There is a $15.00 charge for this service. We will apply the $15.00 charge to any product order.

The following fields are required and must be completed to receive a response.

Name:
Address:
City:
State:		Zip:
Phone #:
Business Phone #:
Email:

VISA MasterCard

Cardholder Name:
Card Number:
Expiration Date:

Personal Information

Medical History: Check box where applicable.

Acne	Acutane	Allergies
Arthritis	Asthma	BirthControl
Blood Disorder	Blood Thinners	Cancer
Diabetic	Eczema	Fever Blisters
Heart Conditions	High Blood Pressure	Hyper/Hypo Pigmentation
Hepatitis	HIV	Hyper/Hypo Thyroid
Insomnia	Medications	Pregnant
Plastic Surgery	Retin A	Scleroderma
Seborrhea	Sensitivities	Skin Cancer
Surgery	Special Diet	Vitamins
Underweight	Overweight	Lupus

Please fill in any details from options above:

Personal Skin Care Routine

Please check current products you use:

	Body Lotion / Cream	Cleansing Cream / Lotion	Day Cream
	Eye Cream	Eye Makeup Remover	Facial Scrub
	Exfoliants	Facial Soap	Body Scrub
	BodySoap	Hand Cream	Mask
	Neck Cream	Night Cream	Skin Freshner / Toner
Other:

Personal Skin Care History

Skin Type:

	Acne		Dehydrated
	Combination		Dry
	Normal		Oily

Do you have problems with breakouts? Yes No How often?

Do you have any problem with your skin getting shiny during the day? Yes No

How was your skin as a teenager?

Do you have any problems with blackheads or whiteheads? Yes No

Do you have any problems with dryness or flakiness? Yes No

Does your make up go on nicely? Yes No

Does your make up last during the day? Yes No

Do you have distended capillaries? Yes No

Do you have hyper-pigmentation? Yes No

Do you have wrinkles? Yes No

Do you have excessive facial hair? Yes No

Do you have dark circles under your eyes? Yes No

Do you have puffiness under your eyes? Yes No

What is your skin texture / color?

Albino	Black		Enlarged Pores	Ethnic
Olive	Pale		Pink	Pitting
Rough	Ruddy		Sallow	Sunburned
Tanned	Thin	Other:

Personal Evaluation

What skin type do you feel you have?

Have you ever had a reaction to a cosmetic or skin care product? Yes No

Where do you purchase most of your face and body care products?

How much time do you spend on your daily skin care / make up routine?

How do you feel about your skin conditions?

What would you like to improve?

Do you tend to tan or burn?

Do you smoke? Yes No

Do you exercise? Yes No How often?

How much sleep do you get per night?

How much do you drink of the following?

Water	Coffee	Tea
Alchohol	Soft Drinks

Please fill in any additional comments you may have below:

An esthetician will personally reply to you within 24 hours.
Thank you for contacting Faces Spa

Faces Spa
8715 Countryside Plaza
Omaha NE 68114
402.384.8400