One on One Consultation Form
Welcome! 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. I look forward to working with you! 🖤 Ashley
Name
*
First Name
Last Name
Email
*
example@example.com
What is the best way to contact you?
Email
Facebook Messenger
Text Message
Other
Please enter your preferred contact information here
(Phone number, etc)
How would you describe your skin?
Dry
Neutral/Normal
Combination
Oily
Not sure
After you wash your face it feels:
Tight or Dry
No particular sensation
Slight sheen
Oily
None of the above
How does your skin feel a few hours after using moisturizer?
Dry
Oily
Dry in some area and oily in others
I don't use moisturizer
None of the above
What are your skin goals? (check all that apply)
Prevent wrinkles
Better, healthier skin
To address my skin concerns
What are your face and/or body skin concerns (check all that apply)
Sensitivity
Redness
Fine lines or wrinkles
Loss of firmness or elasticity
Hyperpigmentation
Acne
Dryness
Rosacea
Dull Skin
Eczema (on face)
Stretch Marks
Eczema (on body including scalp)
Psoriasis (on body including scalp)
Dry/Cracked Lips
Scarring (acne, surgical etc.)
Other
How would you like to get started??
*
Start small and add to my collection with Pom Points (you accrue cash back for every purchase)
Let’s dive in!
What is your price point?
*
$40-$85
$85-$120
$120 and up
Whatever you think I need
Do you wear make-up?
Please Select
Yes
No
Do you have a current skincare routine?
Please Select
Yes
Somewhat
No
If you answered "Yes or Somewhat" to the question above, what does it consist of? (Check all that apply)
Cleanser
Toner
Serum
Sunscreen or moisturizer with SPF
Moisturizer without SPF or face oil
Eye Cream
Retinol or Retin-A
Exfoliant
Other
Are you looking to replace your current skincare routine?
Please Select
Yes
No,just adding on
Possibly
Are you allergic to any skincare ingredients (If Yes, please list them below)
blanks
Are you interested in our body or hair care products?
Yes
No
Are you interested in the Pomifera Opportunity
Yes, sign me up!
I would like more information
Not interested
Questions or comments?
Submit
Should be Empty: