Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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Medical Questionnaire
Are you currently taking any medication prescribed by your GP or any other practitioner? If yes, please list the medication below.
Are you currently planning pregnancy, pregnancy or breastfeeding? If yes, please list them below.
Are you currently taking any vitamins, supplements or Vitamin A medication? Please list below.
Do you have allergies?
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Skin Questionnaire
Do you suffer from the following? Rosacea, Acne, Weakened Skin Barrier, Eczema, Psoriasis, Cold Sores, Hormonal Skin?
What's your skin type? Dry, Oily, Combination, Sensitive?
What are your skin concerns? Fine lines and wrinkles, Sun Damage, Open Pores, Dehydration, Dull skin, Acne /breakouts congestion, Rosacea/ redness /sensitivity, Broken capillaries.
Do you smoke?
On a scale to 1-10 what is your current stress level?
On a scale 1-10 how sensitive is your skin?
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Your current skin care routine
What brand of cleanser/ toner do you use?
What brand of exfoliater do you use?
What brand of moisturiser do you use?
What brand of spf do you use?
What brand of mask do you use?
What brand of eye cream do you use?
Are you happy with your current routine?
Are you looking to change over to Juliette Armand?
What is your main skin concern?
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