Your Skincare Consultation with Jenee'

Your Skincare Consultation with Jenee'

A Licensed Advanced Esthetician of 2 years and a Alternative medicine student here to help ! Fill out the form below so I can recommend the best products and regimen to address your skin concerns.
Date*

DayMonthYear
Date
Full Name*

First NameLast Name
Mobile Number*
Please enter a valid phone number.
Email*
example@example.co.uk
Address (to receive product samples and special offers)

Street Address

Address Line 2

TownCounty

Post CodeCountry
SKIN DIAGNOSIS
Which gender do you identify as?*
Age*

18-2425-3940-5455+
What is your main skin concern?*
Has this always been a concern?*

Yes, my skin has always been this wayNo, my skin has changed recently
I would also like help with: (select all that apply)*

AcneDry, tight feelingOily skinFine lines and lack of toneDeep lines and lack of firmnessLoss of firmnessLoss of radianceVisible/enlarged poresShiny T-zone (forehead, nose & chin)Congested skin (pimples, blackheads etc.)Dry with flaky patchesI have no other concernsOther
Do you have sensitive skin*

YesNo
If 'Yes', what type of sensitivity do you have?

Reactive to environment - touch sensitivity, spicy foods, caffeine, alcohol, temperature or mood changes)Allergic reactions to harsh product ingredients causing redness, itching, swelling etc.Extreme sensitivity e.g. eczema, psoriasis or dermatitisSensitive due to hormonal changesOther
How would you like your skin to look?*
What are your skincare goals?*
What textures do you prefer?*

Thin lotionsLightweight creamsRich creams
What is your preferred method of cleansing your face?*

Face washCleansing waterWipe-off cream cleanserWipe-off cleansing balm
Does your skin feel tight or dry after cleansing?*

AlwaysNeverSometimes
What is your current skincare routine (select all that apply)*

Eye make-up removerFace washCleanserTonerHydrating essenceSerumFacial oilEye creamMoisturiserExfoliator/polish/scrubFace maskOther
Do you treat your skin to an exfoliator, scrub or facial polish 1-2 times EVERY week?*
Do you treat your skin to a face mask 1-2 times EVERY week?*
Additional information
Add any other information that may be relevant e.g. known allergies

Your Skincare Consultation with Jenee'

SKIN DIAGNOSIS