ECLAT SKIN QUIZ

1
Let's get to know each other! What's your name?* This field is required.
First Name
Last Name
2
Nice to meet you! How old are you?* This field is required.
I'm in my teens
I'm in my 20's
I'm in my 30's
I'm in my 40's
I'm in my 50's
I'm 60+
3
What complexion most resembles yours? **REMEMBER YOUR CHOICE, AND INDICATE YOUR SKIN TYPE ON THE NEXT SLIDE**
4
Using the choices above, which skin type do you have?* This field is required.Choose One
Choice 1 - Pale, White
Choice 2 - White, Fair
Choice 3 - Medium White to Olive
Choice 4 - Olive Tone
Choice 5 - Light Brown
Choice 6 - Dark Brown or Black
5
Have you tried medical esthetics before?* This field is required.
No, I'm a Newbie
Yes, I've dabbled in some injectables and lasers
Ha, I'm a seasoned veteran!
6
What concerns you most about your skin?* This field is required.Choose all that apply
ACNE CONTROL
SAGGING / AGING
SUN DAMAGE / SPOTS
TEXTURE / SCARRING
REDNESS / ROSACEA
LINES/ WRINKLES
DRY/ DULL SKIN
CELLULITE/TONE
7
Anything else we should know about you?* This field is required.
I need professional advice about my skin
I have a special event and want to improve body contours
I have a special event and want great skin
I prefer a natural approach to aging (without injectables)
I am interested in holistic wellness & beauty services
8
What's your #1 favorite skin care product?
9
Provide your general health to help us choose the safest treatments for you* This field is required.
Auto Immune / Diabetes
Heart Problems / Pacemaker
Pregnant / Nursing
PCOS or Hormone Imbalance
Accutane / Chemotherapy
Recent Weight Loss / GLP1's
Allergic to Steel / Nickel
N/A None
10
Are you on any antibiotics or medications? * This field is required.
YESNO
11
What is your Cosmetic History?
Facial Surgery
Facial Laser Treatment
Botox or Filler
Accutane Usage
Chemical Peels
Acne Prescriptions / Retinol
Sensitive to Lidocaine
N/A
12
How often do you feel you need facials?
Monthly
Quarterly
Couple times a year
Only before an event
I've never had a facial
13
Would you like to visit to our studio for consultation, or would you prefer an in-home virtual consultation? * This field is required.
14
What benefits are most important to you?
15
Our facials are priced from $55 to $400. Use the slider to indicate your budget for treatment:
16
OPTIONAL: You're unique and so is your skin! For more personalization, please provide us with a photo of your face, showing your main concerns.
17
Have we left anything out? Share any additional details about important health issues, events or needs.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
Please let us know how you heard about us!
Google
Facebook
Instagram
Yelp
Referral
Other
19
Were you a referral? Please mention the name of the person who referred you:
20
Please note without the benefit of a thorough, in person consultation we cannot definitely offer all treatments. The information presented is for educational purposes and does not constitute medical advice. Please provide an email to receive your
Clear
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Note: The information presented is for educational purposes and does not constitute medical advice. This is not a consent for treatment. Please provide an email and click SUBMIT to receive your customized recommendations!* This field is required.
example@example.com
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