About Us
Who We Are
Join Us
Own Your Own ProMD Health
Core Values
Financing & Offers
Shop
The Skin Shoppe
Gift Cards
Shop May Specials
Services
Aesthetic Services
Services for the Face
Neurotoxins
Dermal Fillers
Lasers
Vital Cell Volume Restoration
The Spa by ProMD Health
Kybella
Regenerative Medicine
Services for the Body
Emsculpt NEO
Micro/Nano Fat Grafting
Laser Hair Removal
Tattoo Removal
Wellness Services
Weight Management
Hormone Imbalance
Menopause Management
Longevity/Functional Medicine
Hair Loss
Refill Request
Locations
Annapolis, MD
Arlington, VA
Ashburn, VA
Bel Air, MD
Bethesda, MD
Columbia, MD
Easton, MD
Hutto, TX
Lafayette, CO
Lewes, DE
Timonium, MD
Tox Bar
Tyson’s Corner, VA – Coming soon!
Washington, DC
Wellington, FL
Westminster, MD
ProMD Connect
Group
About Us
Who We Are
Join Us
Own Your Own ProMD Health
Core Values
Financing & Offers
Shop
The Skin Shoppe
Gift Cards
Shop May Specials
Services
Aesthetic Services
Services for the Face
Neurotoxins
Dermal Fillers
Lasers
Vital Cell Volume Restoration
The Spa by ProMD Health
Kybella
Regenerative Medicine
Services for the Body
Emsculpt NEO
Micro/Nano Fat Grafting
Laser Hair Removal
Tattoo Removal
Wellness Services
Weight Management
Hormone Imbalance
Menopause Management
Longevity/Functional Medicine
Hair Loss
Refill Request
Locations
Annapolis, MD
Arlington, VA
Ashburn, VA
Bel Air, MD
Bethesda, MD
Columbia, MD
Easton, MD
Hutto, TX
Lafayette, CO
Lewes, DE
Timonium, MD
Tox Bar
Tyson’s Corner, VA – Coming soon!
Washington, DC
Wellington, FL
Westminster, MD
ProMD Connect
Book an Appointment
1
Contact Information
2
Skin Type and Concerns
3
Current Skincare Routine
4
Lifestyle and Habits
5
Medical History
6
Goals and Preferences
Skincare Questionaire
First Name
Last Name
Email
(Required)
Phone
(Required)
Gender
(Required)
Male
Female
Skincare Questionaire
How would you describe your skin type?
(Required)
Oily
Dry
Normal
Sensitive / Red
Do you have any specific skin concerns?
(Required)
Acne
Blackheads / Whiteheads
Hyperpigmentation / Sun Damage
Melasma
Aging / Wrinkles
Rosacea
Eczema / Psoriasis
Large Pores
Dullness
Other (please specify)
Please specify your specific skin concerns.
Are you currently experiencing any skin irritation or conditions?
(Required)
Yes
No
Please describe your current skin irritation or condition.
Please upload ONE front facing photo of your face
(Required)
Accepted file types: jpg, png, Max. file size: 128 MB.
Please upload ONE left side photo of your face
(Required)
Accepted file types: jpg, png, Max. file size: 128 MB.
Please upload ONE right side photo of your face
(Required)
Accepted file types: jpg, png, Max. file size: 128 MB.
Skincare Questionaire
What products do you currently use and with what frequency?
Please upload ONE photo of your current products in a line with the label facing out in order of use
(Required)
Accepted file types: jpg, png, Max. file size: 128 MB.
Are there any skincare products or ingredients you are allergic or sensitive to?
(Required)
Yes
No
Please specify what skincare products or ingredients you are allergic or sensitive to
Skincare Questionaire
How would you describe your diet?
(Required)
Balanced
High in processed foods
High in fruits and vegetables
Other
Please specify
(Required)
Do you smoke cigarettes?
(Required)
Yes
No
How much water do you drink daily?
(Required)
Less than 1 liter
1 - 2 liters
More than 2 liters
How many hours of sleep do you get on average per night?
(Required)
Less than 5 hours
5 - 7 hours
More than 7 hours
How often do you expose your skin to the sun?
(Required)
Rarely
Occasionally
Frequently
Always wear sunscreen
Skincare Questionaire
Do you have any known medical conditions that might affect your skin? (e.g., diabetes, thyroid issues, hormonal imbalances)
(Required)
Yes
No
Please specify any known medical conditions that might affect your skin? (e.g., diabetes, thyroid issues, hormonal imbalances)
Are you taking any medications that could affect your skin? (e.g., birth control, antibiotics, Accutane)
(Required)
Yes
No
Please specify any medications that could affect your skin? (e.g., birth control, antibiotics, Accutane)
Skincare Questionaire
What are your primary goals for your skincare regimen? (e.g., clear acne, reduce wrinkles, even skin tone)
(Required)
How much time are you willing to spend on your daily skincare routine?
(Required)
Less than 5 minutes
5 - 10 minutes
More than 10 minutes
What is your skincare budget?
(Required)
$100 - $200
$200 - $300
$300 - $400
I don’t have a budget, I want what is best for my skin
Is there anything else you would like your skincare professional to know about your skin or lifestyle?
Comments
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