Name & Surname

Phone

Address

Birthday

How did you hear about us?

Within the last year, have you had any health problems that have affected/ could affect your skin? YES/NO Please specify:

List any medications, supplements, vitamins etc. (incl. oral contraception) that you take regularly

Do you wear contact lenses?

Yes No

Do you have sinus problems?

Yes No

Do you have metal implants, pacemaker or piercings?

Yes No

Do you experience claustrophobia?

Yes No

Please list any allergies:

What are your specific skin concerns/challenges?

Have you had chemical peels, microdermabrasion or resurfacing procedures in the last three months?

Yes No

Have you used Retin-A or prescription skin products in the last 90 days?

Yes No

Are you currently using any products containing the following ingredients?

Please indicate if any of the following apply to you:

I confirm to my best knowledge that the answers I have given are correct and true, and that I have provided any information relevant to my treatment

Our Beauty Bar Aims to deliver the best all over grooming experience and high notch service excellence

Enjoy a 10% discount on your First purchase!

Use:10Coco

Available to the first 20 people.