Online Consultation

Which product(s) are you interested in using? *

Biologique Recherche
Jan Marini Skin Research
Osmosis Wellness
Other

Please specify other products you're interested in using? *

First Name *

Last Name *

Gender * This question allows us to customize the remaining survey questions.

Email *

Phone *

Mailing Address *

City/Town *

Province *

Date of Birth Format: YYYY-MM-DD

Ethnicity *

What are the main concerns with your skin? *

What are your expectations for the treatment and products? *

Current Skin Condition *

Sensitivity / Breakouts *

Present Skin Issue *

Eyes *

Mouth Area *

Cheeks *

Other Skin Issues *

Do you smoke? *

Food / Eating Habits

How much of each of the following do you consume daily? For beverages, a glass is defined as 1 cup (250mL).

Water *

Coffee *

Alcohol *

Pop Drinks *

Potato Chips *

Chocolate *

Fried Foods *

List any supplements and/or vitamins you are taking.

Do you have any allergies? *

Please list your allergies *

Are you currently using a retinol? *

No
0.25%
0.50%
1.00%

Men's Shaving *

No issues
Ingrown hair
Irritation

Is your digestion and elimination normal? *

Are you pregnant? *

Menstrual Cycle *

Regular
Irregular

Are you experiencing stress? *

Photos of Face

We require three specific images of your face in order to prepare your consultation. You accept JPEG and PNG files.

Image of Left Side of Face *

Image of Face (straight on) *

Image of Right Side of Face *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Online Consultation