First Name Last Name Email Cell Number Your Age Which city are you located in? How did you hear about DermoProf Skincare/Who referred you? Select from the following list attributes of your skin type: Do you suffer from breakouts or acne prone skin? YesNo Do you have acne on your chest and back? YesNo Is your skin dry/dehydrated OR dry sometimes, oily sometimes OR oily all the time? Are you taking any medication for acne? If so, which medication? YesNo If not on medication currently, have you ever been on medication for acne/breakouts before? YesNo Please specify which medication,when and for what period? Are you allergic to Asprin or Salicylic acid? Our ACnClear Cream contains Salicylic Acid. YesNo Are you allergic to Almonds? Our ACnClear and PigmentoB Creams contain Mandelic Acid. YesNo Are you pregnant? Our products have not been tested for safety in pregnancy. YesNo Do you have facial hair? Where on your face is hair mainly? YesNo What hair removal method do you use? If you have dark marks/hyperpigmentation, have you been on any products, salon or medical treatment for this? If so, please specify which products or treatment YesNo What products are you currently using on your face? Do you apply foundation, bb cream, powder, concealer or sunscreen everyday? Are you taking any oral or using any topical medication that makes your skin sensitive? YesNo Are you on any steroid or cortisone treatment? YesNo Are you having or have had laser/light treatment done on your face? What type of laser and how many treatments? YesNo Have you had any chemical peels done? YesNo Which products were you using as homecare maintenance during these treatments? Did you see an improvement after these treatments? YesNo Briefly, describe your skin challenges or requirements? Upload Picture Please note: You can upload an image of a section of the face, illustrating your skin type, it does not have to be the entire face.
