New Client Consultation Form

Hey Beauty!

We are so excited that you are ready to take control of your skin's health! Whether you're a long-time skincare advocate, or wanting to get a fresh start to your skin's best glow, we're here to help! Below are a series of questions that, when answered as thoroughly as possible, will help us determine the best possible solution for your path to acheive your best, healthiest, most youthful and vibrant skin!

Once you submit your request we will get to working on building a skincare regimen for you. We require a $50 fee for your skincare regimen, which you will later be able to use towards your skincare products that you purchase from us. Look out for an email for your $50 regimen builder fee, and once recieved you regiment will be built and sent to you. When you are ready for your products you can pick them up in our office, or we can ship directly to you! Any purchases of $299 or more will get free shipping. Purchases under will pay a flate rate of $10 for shipping.

Please allow us 24 hours to get back to you. If, for some reason, you don't hear from us within 24 hours, please send us a quick message and let us know. This typically means there was a disconnect somewhere and we didn't receive your submission.

xoxo,

Beauty Refined Team

Name*

First NameLast Name

Gender

Date of Birth*

Email

example@example.com

Mobile Number*

Area CodePhone Number

Mailing Address*

Street Address

Street Address Line 2

BarangayCity

ProvinceCountry

What is your preferred method of communication?*

How did you hear about us?*

If Referral, please list name

If Other, please let us know

Do you have any allergies?

Do you have sensitive skin?

Do you have a brand preference?

What is your skin type?

Normal to DryNormal (all skin types)Normal to Oily

Type a question

If you choose acne, How severe is it?

If you have redness how severeis it?

What are your skin care goals?*

Acne FreeWrinkle FreeBrighterYounger Looking

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?*

YesNo

If Yes, when?

What Skin Care Products do you currently use?*

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Please specify which product or type, if you answered 'Yes, currently using' to above.

If checked, please note last time.

Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo

Are you preparing for a pre-procedure or event? If so, which one?

FEMALE CLIENTS

Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A

If yes, please specify

Please upload a photo of your face for specific areas of concern. Please take in good lighting.

Browse Files

Thank you for taking the time to share your skin health with us. We will be happy to help customize a regimen to help reach your skincare goals. You will be hearing from us soon with a customized regimen recommendation!

Best,

Annette Wychgram NP-C

&

Leah Block, LE

Beauty Refined Team

Skincare Regimen Builder

Tell us about your skin

Your Health