Skincare Consultation Form
Simply Massage & Wellness
Name
*
First Name
Last Name
Email
*
example@example.com
What are your main concerns about your skin? Select all that are applicable.
*
Dryness
Aging / Fine Lines and Wrinkles
Acne / Blemish Prone
Redness
Discoloration
Dullness
Oily Skin
Enlarged Pores
Sun Damage
Sensitive Skin
Other
If selected 'Other' in the previous question, please explain.
What's your skin type?
*
Dry
Oily
Combination
Balanced
Unsure
What is your age?
*
Under 18
18 - 25
26 - 35
36 - 45
46 - 55
56 - 65
Over 65
If you have fine lines and wrinkles in what areas do they exist? Select all that are applicable.
*
Forehead
Eyes
Mouth
Cheeks
Neck
All of the Above
None
Do you have any allergies or sensitivities?
*
Are you currently pregnant or breastfeeding?
*
Yes
No
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.
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Is there anything else you'd like your Esthetician to know?
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