Welcome to Your One on One Skincare Consultation with Jamie Delorge!
I am excited to work with you and learn more about you and your skin! Once I have your responses, I can give you a personalized skin care routine using our clinically proven Pomifera products. Please allow up to 24 hours for a response.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
What is the best way to contact you?
FB Messenger
Text Message
Instagram
Email
Other
How would you describe your skin?
Dry: My skin feels tight and has several dry patches.
Normal: My skin is neither oily or dry.
Combination: My skin is both oily and dry.
Oily: My skin starts producing oil almost immediately after washing.
Acne Prone: My skin breaks out often
How does your skin feel a few hours after using moisturizer?
Dry
Oily
Dry in some areas and oily in others
I don’t use moisturizer
None of the above
What are the main skincare concerns you would like to address? (Check all that apply)
Uneven skintone
Redness/Inflammation
Wrinkles/Fine Lines
Acne
Dryness
Rosacea
Hyperpigmentation
Dull skin
Eczema (on face)
Eczema (on body and scalp)
Psoriasis (on body and scalp)
Dry/Cracked lips
Cold Sores/Fever Blisters
Scarring (acne, surgical, etc.)
Enlarged Pores
Under eye bags, Darkness, Puffiness
Melasma
Other
How old are you?
20 or below
21-26
27-33
34-39
40-46
47-54
55-64
65 or older
Are you interested in a tinted BB Cream with SPF 30?
Yes
No
I’m not sure!
Do you wear makeup?
Please Select
Yes
No
Sometimes
What’s your skincare budget?
&40-$75
$75-$100
$100+
Do you have any questions or comments?
Submit
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