Online Skin Consultation 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.
Date
-
Month
-
Day
Year
Date
Medical Questionnaire
Are you currently taking any medication prescribed by a GP or any other practitioner? If yes, please list the medication below.
Are you currently pregnant, trying to conceive or breastfeeding?
Are you currently taking any vitamins, supplements or Vitamin A? Please list below.
Do you have any allergies
Skin Questionnaire
Do you suffer from any of the following?
Rosacea
Acne
Weakened Skin Barrier
Eczema
Psoriasis
Cold sores
Hormonal skin
What is 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
Loose skin
Pigmentation
Rosacea/Redness/Sensitivity
Broken Capillaries
Do you smoke?
On a scale of 1-10, what is your current stress level?
On a scale of 1-10, how sensitive is your skin?
Your Current Skincare Routine
What brand of cleanser/toner do you use?
What brand exfoliant do you use? Scrub/acids or enzymes?
What brand serums do you use?
What brand moisturiser do you use?
What brand SPF do you use?
What brand mask do you use?
What brand eye cream/gel do you use?
Are you happy with your current routine?
Are you looking to change over to Juliette Armand Skincare?
Yes, a whole new routine
Yes, to add in a few products
Yes, to add in a missing step
No, I'm happy with my current routine
What is your main skin concern?
Please upload clear up-close, make up free, unfiltered pictures of your skin in good lighting
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