Beauty has never been an exact science until now

Home   Biomani Boutique   Shop on Line

 

                                                

 
Your skin protocol
Biomani Boutique
Request a Catalogue
Shop on Line
Have a Question ?
Editorial
Contact Us
Links

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your skin Evaluation
All the information is strictly confidential is not released to any source whatsoever
Our response will be emailed to you
WE will not respond to any request with incomplete information

Sex          male   Female
Age   
Full Name   
Street Address   
City   
State, Zip   
Country   
Telephone   
Email   

Skin Evaluation

1- Are you pregnant or breast-feeding? Yes     No
2- Do you smoke?  Yes         No
3- Have you undergone laser resurfacing in the last 4 months?
Yes             No
4- Which of the following describe best your skin?
    Somewhat oily in T-zone but not all over
    Dry all over
    Sensitive and dry all over
    Oily
    Blemished and with problems
    Sun and environmental damage
5- Have you been diagnosed with any of the following:
    Acne or deep cystic acne
    Rosacea with dry and sensitive skin
    Keratosis Pilaris
    Eczema or Psoriasis
    Dermatitis or Folliculitis
    Ingrown hair
6- Do you have Acne breakouts?
    Never
    Occasional
    Once monthly
    Persistent
7- Are you allergic to any of the following?
    Alpha or Beta hydroxy acids
    Hydroquinone
    Benzoyl Peroxide
    Sulfur
    Others
8- Are you on any of the following medications?
    Accutane
    Retin-A or Renova
    Differin or Azelex
    Metrogel cream
    Birth control pills or Hormone replacement
    Vitamins
9- Do you have facials?     Yes       No
     How often?
10- Do you use sun screen daily?   Yes         No
11- Do you exercise?  Frequently     Occasionally
12- How many glasses of  water do you drink daily?
    8     6      4      2
13- What is your level of stress?
    none      Low       Medium       High
14- What additional results are you looking for?
    Improve skin tone and texture
    Fade and remove pigmented and dark spots
    Control excess oil
    Restore skin elasticity and firmness
    Diminish wrinkles and fine lines
    Diminish eye area Puffiness and dark circles
    Minimize pores
    Clear black and white-heads
    Clear Acne and Blemishes
    Improve acne scarring
    Increase hydration and softness
    Treat ingrown hair    

15- Is there anything else about your facial skin you would like to discuss?

By submitting this form I acknowledge that I have read and understood the following:
This questionnaire submitted online cannot substitute for in- person consultation with licensed aesthetician or doctors. The Specialists-team of Biomani Scientific SkinCare analyzes your skintype and suggests products based on the completeness and accuracy of the information provided by you. If you are not satisfied with any product purchased by you in response to Biomani Specialists-team, return it within two weeks of the date of purchase for full refund (less S&H).

back to the top