Skin Analysis Form

Concerns with your skin? Looking to start a new skin care routine? We can help!

Fill out the form below and click send, and our licensed skin therapist will get back to you as soon as possible with product recommendations and proper skin care information to get you started towards your best skin ever!

Note: For a face-to-face and complimentary skin analysis in the boutique, please call (204) 268 2933 or click BOOK ONLINE.


Name (required)

Email (required)

Phone Number:


 Under 21 21-30 31-40 41-50 51-60 60+

To begin, we need to know a few things about you:

1) Is this your first introduction to Dermalogica or Image Skincare?  Yes No

2) Have you ever used professional grade skin care products before?  Yes No

3) Are you currently undergoing any medical skin procedures or using any oral or topical medications or exfoliants that may impact your skin?  Yes No

What are your specific concerns or challenges you are having with your skin?

What skin care products are you currently using on your face?

 Soap Cleanser Toner Moisturiser Masque Exfoliator Eye Products Serums SPF

What skin type are you?

 oily oily/normal normal normal/dry dry mature

Do you ever experience these conditions on your skin?

 flakiness tightness obvious dryness burning itching or stinging sensations

Do you have a tendency to redness?

 Yes No

Are you currently experiencing a breakout?

 Yes No

Do you have any allergies?

 Yes No

What are you looking for in a skin care routine or product, that you feel you are not currently getting?

Are there any other concerns, questions or comments you would like to share?

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