Pigmentation Cream Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What are your skins concerns? * Sundamage Uneven Skin Tone Blotchy Skin Melasma Pigmentation from acne Fine lines/wrinkles Have you ever used Hydroquinone? Yes No Unsure If yes, When and for how long? Have you ever used Retinol/Retinoid? * Yes No Unsure If yes, When and for how long? Do you have any allergies? * Yes no If yes, to what? I Understand: * I will be required to submit 3 photos (Front facing, right facing, left facing) after the submission of this form. The form will automatically redirect you to email: Ronicha@airofearth.co Terms and Conditions: * This Questionnaire is for informational purposes only. The content is not intended to be a substitute for medical advice, diagnosis, or treatment, and does not constitute medical or other professional consultations. (Please refer to https://pocketsuite.io/book/ronicha-palmer to reserve an in person or virtual consult for a more guided routine). The information provided on all websites associated with Air of Earth Aesthetics, is designed to support, not replace, the relationship that exists between patient/site visitor and his/her physician/provider. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on our websites. Thank you! Please email 3 photos to RONICHA@AIROFEARTH.COPlease note it’s .co NOT .com