Skincare Consultation Form

1
Date* This field is required.
Date
Day
Month
Year
2
Name* This field is required.
First Name
Last Name
3
E-mail* This field is required.We are committed to protecting your privacy and will not share your personal information with any third parties. Your data is used solely for the purposes you have authorized and is handled with the utmost care and security
example@example.com
Confirm Email
4
Phone Number* This field is required.
5
What is your age group?* This field is required.
16-18
19-29
30-39
40-49
50-59
60+
6
What is your date of birth?* This field is required.
Date
Day
Month
Year
7
How would you describe your skin?* This field is required.
Normal Skin ( clear in appearance neither tight nor greasy )
Oily Skin ( shiny often has breakouts )
Dry Skin ( feels tight and irritable, often looks flaky )
Sensitive Skin ( often experiences redness and reactivity )
8
What are your skin care goals?* This field is required.
9
What are your skin care challenges?* This field is required.(you can select multiple choices)
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
10
If you wish to upload a photo of your skin please upload below
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
If Yes, please specify what treatment you had and when it was
12
If you wish to upload a photo of your skin please upload below(it can help us recommend products suited to your needs)
13
Do you currently use Skin Care Products?* This field is required.
No
Other
14
What do you use?
15
Have you ever used ZO Skin Health or Obagi products in the past?* This field is required.
No
Other
16
Do you/have you used Retin-A, Roaccutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?* This field is required.
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
17
Have you received any of these hair removal services to the face in the last 30 days?* This field is required.
Waxing
Sugaring
Threading
Electrolysis/ Laser
Depilatory Cream
Shaving
None
18
Have you ever received any facial cosmetic surgery in the past month (including chemical peels, laser services, or microdermabrasion treatments)?* This field is required.(if yes we recommend not starting your product till a month has passed or the healing process has completed)
No
Other
19
Have you experienced any of these health conditions in the past or present?* This field is required.
Diabetes
Auto-Immune Disorders
Frequent Cold Sores
Lupus
No
Other
20
If you have any other medical conditions please list(if none state 'none')
21
Do you have any allergy to: Lactic Acid/ Citric Acid/ Salicylic Acid/ Retinol (Vitamin A)* This field is required.
Yes
No
22
Please list any medications you are on (if you are on none leave blank)
23
Are you currently prescribed any medications (topical or oral) for acne / acne control?* This field is required.
No
Other
24
If yes, please specify what and date last used
25
Type a question
26
Are you pregnant or trying to become pregnant?* This field is required.(If this is not applicable select N/A)
Yes
No
Recently had a baby and am breastfeeding
N/A
27
Any other information you feel we need to know
Huge
Large
Normal
Small
Ok
Ok
28
Type a question* This field is required.How did you hear about us?
Please Select
Please Select
Instagram
Leaflet
Facebook
Google
TikTok
Pinterest
Twitter
Word of Mouth
29
Terms and Conditions* This field is required.
30
Signature* This field is required.
Powered by Jotform SignClear
31
Approval StatusApproval Status
Approval Status
Should be Empty: