Bespoke Skin Care Consultation Form

When filling in this consultation please complete all sections to help give us the information we need to make your produts with the best ingredients to suit you.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

area code Phone number

Mobile

country code mobile number

Date of Birth

Date

What changes are you hoping to see in your skin ?

What skin care range do you normally use?

When you first wake before applying moisturiser does your skin feel tight?

Do you have clogged pores (Blackheads or whiteheads)

Do you have fine lines or wrinkles?

Do you have acne or spots?

Does your face get red after moderate exercise or stress?

After a spot or cut do you develop a dark brown or black spot?

Do you suffer with pigmentation (Freckles or brown spots, (sometimes referred incorrectly as age spots)?

Do you have enlarged pores?

Have you engaged in tanning for more than 2 weeks per year?

When you are exposed to the sun do you?

Do you wear SPF or Sunscreen?

Do skin care products cause you to itch, break out or sting?

Are you pregnant or breast feeding?

Are you taking any prescription medications?

If yes , which ones?

Is there any medical History that has affected your skin?

Do you have any allergies to Skin care ingredients, essential oils, or any particular skin care make?

If yes please specify which ones

Aromas you prefer

What consistency do you prefer for your facial cream

Do you require Vegan Ingredients

Can we have a selfie?

Sure

Any area of worry for you if we cannot have a face to face consultation

What Organic skin care products are you looking For?

What service are you looking for

Would you like to join our mailing list

I confirm that the information I have given is correct to the best of my knowledge

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