Name
*
Instagram Username and-or phone number
*
Email
*
Is your scalp...
Dry
Oily
Nuetral
How often do you wash your hair?
Daily
1-2 days
4 days+
Is your hair
Curly
Wavy
Straight
Is your hair color treated?
Yes
No
Biggest hair concern-issue...
Examples: Frizz, won't grow, oily, thin, broken etc.
How often do you use heat tools?
What brand do you currently use?
Is your skin...
Oily
Dry
Neutral
Do you currently have a skincare routine?
Yes
No
When you wash your face do you cleanse twice every time?
Yes
No
Sometimes
What's your biggest skincare concern?
Wrinkles / fine lines
Acne / scars
Uneven skin tone
Other
Do you currently have a wellness routine that includes vitamins / supplements?
Yes
No
If yes, tell me about what you currently use.
What are you looking to improve in your health?
Examples: Gut health, immune health, more energy, better sleep etc.
Submit
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