Bella's Apothecary
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Home
Shop with Bella
Harmony Skin Brightening Special
Tame Your Beard - Tame Tangerine Special Offer
Bella's Corner
Manifestation Journal
Contact
Follow & Contact
Standard Skincare Consultation Questionnaire
*
Indicates required field
Name
*
First
Last
Birthday mm/dd/year
*
Email
*
Phone Number
*
Skin Concerns & Goals
*
If there was something you could change or improve about your skin, what would it be?
Skin Type
*
Normal
Oily
Dry
Combination
Sensitive
Skin History
*
Dry
Discoloration
Fine Lines & Wrinkles
Rosacea
Acne Scarring
Enlarged pores
Acne Breakouts
Uneven texture
Sun Damage
Dark Under-Eye Circles
Please check any of the following that apply to you
Morning Skincare Routine
*
Evening Skincare Routine
*
How often do you currently cleanse, exfoliate, and moisturize?
*
Do you experience seasonal changes in your skin? If so, what are they?
*
What’s your budget for skincare products? (Drugstore, Luxury, Mix of Both)
*
Allergies/Sensitivities
*
Medical Information
*
Pregnant
Diabetes
Autoimmune Diseases
High Blood Pressure
Nursing
Epilepsy or Seizures
Heart Disease
Asthsma
Hormone Replacement Therapy (HRT)
Please check any of the following that apply to you
What products are you currently using in your routine (if any)?
*
How much time are you willing to spend on your skincare routine?
*
Do you use sunscreen regularly? (If yes, what SPF?)
*
Consent & Agreement
*
I understand that the recommended treatment is not a substitute for medical treatment or advice. I have provided accurate information to the best of my knowledge. I consent to the facial treatment and agree to follow the recommendations for aftercare and skincare.
Your information is confidential and will only be used for this consultation.
Submit
Home
Shop with Bella
Harmony Skin Brightening Special
Tame Your Beard - Tame Tangerine Special Offer
Bella's Corner
Manifestation Journal
Contact