Skin Consultation Form

Skin Care Consultation Form

Your skin is unique, and your routine should be too. This in-depth consultation is designed to help you understand your skin better and get expert guidance tailored specifically to your concerns, skin type, and lifestyle. For R100, you will receive a detailed, custom-curated skin guide with personalised product recommendations and a step-by-step routine designed to give you real, lasting results. No more trial and error, no more wasted money on products that don’t work. This is your chance to get a skincare plan that is clear, effective, and made just for you. Once you complete the form, you will receive an invoice, and upon payment, your personalised skincare guide will be created. Spots are limited, so don’t miss out—fill out the form below and start your journey to healthier, more radiant skin.
Personal Information
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Location *

Country, City, Suburb

Street Address Line 2

State / Province

Postal / Zip Code
I work indoors most of the timeI work outdoors most of the timeI exercise regularlyI experience a lot of stressI travel frequently
Skin Profile
What are your skin care goals? *
AcneHyperpigmentationUneven skin toneDryness/dehydrationOily skinSensitive skinRosaceaFine lines/wrinklesLarge poresDull skinSkin texture issuesOther
NormalOilyDryCombinationSensitiveUnsure
Tight and dryBalancedOily/shinyDry in some areas, oily in others
NoYes (Please Specify)
Please feel free to go into more detail if "Yes"
Frequent breakoutsCystic acneRedness or irritationFlakinessExcess oil productionSun sensitivityBurning/stinging when using skincare
Current Skincare Routine
CleanserTonerExfoliatorSerumMoisturizerFace oilSunscreenSpot treatmentEye creamFace masksNone
Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Daily2-3 times a weekOnce a weekRarely/Never
Yes, every daySometimesOnly when I’m outsideNo
YesNoI don’t know what that is
Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Diet & Lifestyle
Less than 1L1-2LMore than 2L
I eat mostly whole, unprocessed foodsI eat a mix of healthy and processed foodsI eat mostly processed or fast food
Less than 4 hours4-6 hours6-8 hoursMore than 8 hours
Do you take any supplements? (e.g., collagen, vitamin C, omega-3, probiotics)
Yes, frequentlyOccasionallyNo
Hormonal & Medical Considerations
YesNo
If yes, please specify.
YesNoNot sure
Do you have any medical conditions that impact your skin (PCOS, eczema, psoriasis, etc.)?
Goals & Expectations
Clear acneFade dark spotsReduce fine linesHydrated, glowing skinMinimize poresStrengthen skin barrierControl oil productionEven skin toneImprove texture
Yes, I’m willing to change everythingYes, but I’d prefer minimal changesNo, I’d like to work with what I already have
Yes, under R500Yes, R500-R1500Yes, R1500+No set budget
I’m patient and willing to waitI want to see results within a few weeksI need fast results
MALE CLIENTS
Razor / Wet shaveElectricN/A
YesNoN/A
Final Thoughts
Do you have any specific concerns or questions for me?
Product recommendationsRoutine guidanceBoth
Should be Empty:

Skin Care Consultation Form

Personal Information

Skin Profile

Current Skincare Routine

Diet & Lifestyle

Hormonal & Medical Considerations

Goals & Expectations

Final Thoughts