Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
What type of skin do you have? *
Include cleanser, toner, day moisturizer, night moisturizer, SPF, exfoliant, treatments, or masks if applicable.
Please check all areas of concern regarding your skin: *
Please check all areas of concern regarding your eyes: *
Please check all areas of concern regarding your lips: *
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Meghana Prasad, LE from liability and assume full responsibility thereof. *