Skin Questionnaire
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What Products are you currently using:
Have you experienced sensitivity or allergic reactions from any skin care products in the past? If yes, please explain.
Are you using any topical prescriptions from a Medical Professional/Physician? If yes, please list the products.
Are you currently using any products that contain retinol?
Yes
No
Are you currently on birth control or hormone replacement therapy? If yes, please list.
Do you take any vitamins/supplements? If yes, please list.
Check the box that matches your skin type best:
Oily
T-zone oily (combination)
Dry
Normal
What are your top 3 main concerns with your skin?
Wrinkles
Acne
Pigment (discoloration of the skin)
Redness/Rosacea
Dryness/Dry Patches/Eczema
Enlarged Pores
Blackheads
Clogged Pores
Other
How committed are you to a morning and evening skin care routine?
Very
Somewhat
I'll only do the minimal
How many steps are you willing to do morning and night?
1-3
4-5
6-8
As many as it takes
Are you okay with redness and flaking over the course of 6-8 weeks if it means your skin health and appearance will improve?
Yes
No
Have you had any skin treatments in the past (lasers, peels, injections, etc.)? If yes, what and when?
What is your monthly budget for skincare?
$0-$100
$100-$200
$200-$300
No budget
Submit
Should be Empty: