PVP 2.0 Template: Experience Customization Form

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STEP 1: please fill out this form in its entirety in order for us to send back recommendations

STEP 2: I look forward to taking care of you. See you soon! Look for an email back from us within 2 bussiness days

2

Name

First Name

Last Name

3

Today's Date

Date

4

Email

example@example.com

6

Do you wear makeup daily(complimentary Items)

no

yes

sometimes

7

Do you smoke or use tobacco products

yes

no

8

Have you ever been diagnosed with any of these skin conditions

Rosacea

Hormonal acne

Eczema

Other

10

Are you currently experiencing any active breakouts

no

mild

moderate

severe all over

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What is your current stress level

none

mild

moderate

high stress

12

do you work outside

yes

No

13

Have you had a professional skincare treatment beforePlease leave details facials, microneedling laser prp ect

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Do you currently have tox or fillerExplain in detail

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Do you have any special occasions you are preparing forIf yes, provide date of occasion

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Are you currently using any of the following prescription skincare medications

antibiotic topical

steroids

retinol/ tretnion

antibiotic oral

none

17

Would you prefer a treatment plan that focuses on

Immediate visible results

long term improvement and maintenance

both

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Do you currently have a daily skincare regimencheck all that apply

yes day and night

not at all

yes but I am not consistent

no, I just don't know where to start

Yes but only cleanse and moisturize

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If you have a budget for skincare treatments and products please provide a range belowyou can also provide monthly budget if wanted

20

Do you have any medical history that may affect your skin

Diabetes

Hormonal imbalances

Autoimmune disorders

Other

21

Have you ever had an allergic reaction to products or ingredientsIF yes describe what it was

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When providing recommendations, check all you would be interested in learning more about

Specific facials

Laser

At home skincare regimen

tox & injectables

other medi-spa services

peels ( light or deep)

23

Are you pregnant or nursing

YESNO