Skincare Consultation Form
Simply Massage & Wellness
What are your main concerns about your skin? Select all that are applicable.
Aging / Fine Lines and Wrinkles
Acne / Blemish Prone
If selected 'Other' in the previous question, please explain.
What's your skin type?
What is your age?
18 - 25
26 - 35
36 - 45
46 - 55
56 - 65
If you have fine lines and wrinkles in what areas do they exist? Select all that are applicable.
All of the Above
Do you have any allergies or sensitivities?
Are you currently pregnant or breastfeeding?
Do you chemically or physically exfoliate your skin? If so, with what product and how often.
What skincare products are you currently using?
Do you currently use any FarmHouse Fresh products? If so, which ones?
If you'd like, upload a photo that shows your skin concerns. This will help our Esthetician to understand your issue better.
Drag and drop files here
Choose a file
Is there anything else you'd like your Esthetician to know?
Should be Empty: