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14
Questions
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
What’s your skin type ?
Dry
Oily
Sensitive
Normal
Combination
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5
How often do you wash your face?
Once a day
Twice a day
Other
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6
Are you prone to breakouts ?
YES
NO
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7
Do you have dark under eye circles ?
YES
NO
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8
What is your biggest concern?
select all that apply
Fine lines and wrinkles
Dullness
Dehydration
Acne
Large pores
Uneven tones
Other
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9
Do you have dry or flakey patches?
YES
NO
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10
What are your goals for your skin?
Clear skin
Hydrated skin
Smooth skin
Plump tight skin
Bright radiant skin
Other
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11
Do you wear makeup?
If so, how often?
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12
What is your budget?
$105 - $120
$120 - $145
$145 - $165
$165 - $200
Other
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13
When would you like to start ?
-
Date
Year
Month
Day
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14
Are you interested in becoming a market partner and having your own business?
YES
NO
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