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Amirah G. loves to answer questions that provide both women and men with personalized beauty advice and guidance.  Whether it's a simple product question, advice on a new makeup or skin care routine, or if you seek our opinion on the "validity" of the latest beauty trends - why not take the time to tell us a little about yourself (Please provide as much information as possible - and let us know if you would like to see your question posted on our Q&A's section - names withheld).  Please fill out the form on the left or:

E-mail us at amirah@amirahg.com 

**If you would like an Amirah G. product prescription/consultation, please place your order on our website, then be sure to fill out our Online Consultation Card below, and  indicate the desired product line for your prescription.  If we feel that any products selected on your order are not appropriate for your skin type/concerns, you will be contacted, and your order will be adjusted before shipment.**

If you have questions, or would like more information, please leave your name and contact information.

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On-Line Amirah G. Consultation Card


The purpose of this Consultation Card is to correctly evaluate your special skin care needs and concerns.  After placing your order, please fill out our Consultation Card below to confirm that your  product selections are appropriate for your skin type and/or skin concerns. 

If you prefer, you may also call us after placing your order, at 800-975-6290 (Customer Service)  for a telephone skin care/product consultation, Mon-Fri from 12pm-6pm.


This information is confidential, and will not be passed on to a third party.
For an accurate reply please fill in ALL the necessary details below:

INTRODUCTION
My Name or Order # is:
 *
My E-mail Address is:
 *
My Telephone Number is:
 *
My Age Bracket is:
You are interested in a skincare consultation/prescription for which product line?
 
MEDICAL HISTORY
Witihin the past 6 months have you been prescribed medication by a Physician?
Within the past 6 months have you been prescribed medication by a Dermatologist?
Within the last year have you undergone any surgery?
If Yes please specify
 *
Have you had any of these health problems in the past or present? (Please select)
Cancer
Diabetes
Epilepsy
Heart Problem
Hormone Imbalance
Spinal Injury
Hysterectomy
Thyroid Condition
Varicose Veins
Systemic Disease
List any medications supplements vitamins diuretics slimming tablets etc. that you take regurlarly
Do you smoke?
Do you excercise regularly?
Do you follow a restricted diet?
Do you have regular sleep paterns?
Do you wear contact lenses?
Do you have metal implants or pacemaker?
 
YOUR SKIN
With what temperature of water do you cleanse?
Do you have any special skin problems pertaining to your face or body?
If Yes please specify
Are you using any of the following skin care products? (Please Select)
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliater
Eye Products
Other skin care products please specify
EXFOLIATION HISTORY
Have you ever had chemical peels laser or dermabrasion?
in the last month?
Do you use Retin A Renova or Adapalene?
in the last 3 months?
Do you use an acne medication?
in the last 6 months?
If Yes which drug
Are you currently using any products that contain the following ingredients? (Please Select)
Glycolic Acid
Lactic Acid
Any exfoliating scrubs
Any hydroxy acid product
Vitamin A derivatives (ie.retinol)
MOISTURE HYDRATION
How much plain water do you consume daily?
How many alcoholic beverages do you consume weekly?
Do you ever expeience these conditions on your skin? (Please Select)
Flakiness
Tightness
Obvious Dryness
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
Do you sunbathe?
CAPILLARY ACTIVITY
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
Do you suffer from sinus problems?
OIL SECRETION
Do you ever experience oily shine during the day?
Do you ever experience skin breakouts?
NERVE ACTIVITY
Do you drink caffeinated beverages (coffee tea soft drinks)?
How many daily?
Do you ever experience a burning itching sensation on your skin?
What is your pain threshold?
Have you ever experienced claustrophobia?
What type of massage pressure do you prefer?
Have you ever had a reaction to any of the following? (Please Select)
Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy Acids
Animals
Fragrance
Sunscreens
Other (Please Specify)
FEMALE CLIENTS ONLY
Are you taking oral contraception?
Are you pregnant or trying to become pregnant?
Are you lactating?
MALE CLIENTS ONLY
What is your current shaving system?
Do you experience irritation from shaving?
Do you experience ingrown hairs?
CONCLUSION
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
Please provide us with any additional information here:
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We DO NOT share or sell any of your personal information.

Order securely online or, if you prefer:

To order by phone call Toll Free:
(800) 975-6290


Free 3-5 Day Ground Shipping for all orders shipped within continental U.S.!!!
(AK, HI, and PR are shipped via USPS Priority Mail for a flat fee of $25.00)

 

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