A treatment with you in mind.
Thank you for Vonetta Cosmetics (located inside of Aloha waxing studio) for your skincare needs. Answer the questions below so that we may have a better understanding of your general health and lifestyle, this will allow us to design an experience just for you! This questionnaire is completely confidential.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Birth Date
*
Please select a month
January
February
March
April
May
June
July
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October
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Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
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2012
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Year
City
*
State
*
How did you hear about us?
*
Please Select
Google
Yahoo
Bing
Social Media
Natural Girls Rock
Other
If Others, please specify?
1. Please list any chronic health problems which you have/have had:
*
Arthritis
Asthma
Cancer
Diabetes
Heart Disease
High Blood Pressure
Obesity
None
Other
2. Please list all medications you take or use regularly.
*
Accutane
Arthritis
Asthma
Birth Control Pills
High Blood Pressure
Hormones
RetinA
Vitamins
Water Pills
None
Other
3. Are you pregnant?
*
Please select one
No
Yes
4. Do you have permanent face make up?
*
Please select one
No
Yes
5. Of the foods listed below, can you pick some of your favorites?
*
Salty
Sweet
Fast Foods
Fresh Fruit
Fresh Vegetables
Chocolate
Cheese
Dairy
Milk
Peanuts
6. Do you drink coffee, tea or alcohol?
*
Coffee
Tea
Alcohol
N/A
7. How many cups of water do you drink per day?
8. Are you allergic to any of these ingredients?
*
Sulfur
Hydroquinone
Salicylic Acid
Aspirin
Benzoyl Peroxide
N/A
Other
9. Do you have any seasonal or environmental (grass, pet danders, pine tree...etc) allergies?
*
Grass
Pet Danders
N/A
Other
10. If you do have an allergy listed above, do you take allergy medicine regularly to control your allergies.
*
Please select one
No
Yes
11. Do you smoke (cigarettes or recreational products)?
*
Please select one
No
Yes
How many per day?
12. Are you currently experiencing skin problems? If so what kind?
*
Acne
Dark Eye Circles
Dry Skin
Rough Texture
Dark Spots
Dark Patches
Eczema
Large Pores
Oily Skin
N/A
Other
12-a. If you are having an issue with acne are your pimples big and painful?
*
Please select one
No
Yes
12-b. Small and gritty?
*
Please select one
No
Yes
12-c. Are your breakouts worse at cycle time?
*
Please select one
No
Yes
13. Do you play sports or work out?
*
Please select one
No
Yes
14. Does your skin sting when you do your skincare routine?
*
Please select one
No
Yes
15. Please describe your skincare routine morning/evening? (Use product names)?
16. Please provide additional information if needed?
Photos
Please upload 3 pictures of your face. Left side, Right side and Front. This will allow us to have a better understanding of your skin and any issues you may be facing.
Left Side Image (no makeup please)
Upload a File
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Choose a file
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of
Right Side Image (no makeup please)
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of
Front Image (no makeup please)
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of
Required
*
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