Skin Analysis Form
Your Contact Details
(We’ll use this to get in touch and tailor your recommendations)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Tell Us About Your Skin
(Help us understand your skin concerns and type)
What skin concerns are you currently experiencing? (Please tick all that apply):
*
Acne / Breakouts
Dark Spots / Hyperpigmentation
Redness / Rosacea
Sensitivity
Dehydration
Fine Lines / Wrinkles
Oiliness
Dryness
Uneven Tone / Texture
Dullness
Congestion
Loss of Elasticity
Scarring
Enlarged Pores
Other
If you selected 'Other', please provide additional details below:
How would you describe your skin type?
*
Dry
Oily
Combination
Normal
Sensitive
How would you describe your current stress level?
*
Low – I feel calm and in control most of the time.
Moderate – I feel stressed sometimes, but it's manageable.
High – I often feel overwhelmed or tense.
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Allergies, Sensitivities & Medications
(Important info to keep your skin safe)
Do you have any known allergies or sensitivities?
*
Yes
No
If yes, please list them below:
Have you ever had an adverse reaction to a skin product or treatment?
*
Yes
No
If yes, please provide more details below:
Are you currently taking any medications?
*
Yes
No
If yes, please list them below:
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Your Current Skin Care Routine
(Let us know what products you’re using now)
Which of the following skin products do you currently use? (Select all that apply)
*
Cleanser
Toner
Moisturiser
Sunscreen
Exfoliant (scrubs or acids)
Serums (like vitamin C or hyaluronic acid)
Retinoids (prescription or over-the-counter)
Acne treatments (benzoyl peroxide, salicylic acid)
Masks (hydrating, clay, peel-off, etc.)
Eye cream
None
How often do you follow your routine? (Daily, Occasionally, Rarely)
*
Daily
Occasionally
Rarely
How often do you receive professional treatments? (i.e facials)
*
Once a week
Once a month
Every few months
Never
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Your Skin Goals & Preferences
(What results you’re aiming for and your product preferences)
What results are you hoping to achieve? (Select all that apply):
*
Hydration
Clearer skin / Acne control
Reduce redness / sensitivity
Even skin tone
Anti-ageing / Reduce fine lines & wrinkles
Minimise pores
Brightening / Radiance
Other
If you selected 'Other', please specify:
Are you open to trying new products or treatments?
*
Yes
No
Maybe
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Upload a Photo & Share Your Confidence
(We want to see your skin and hear how you feel about it)
Please upload a clear photo of your skin taken in good, natural lighting.
*
Browse Files
Drag and drop files here
Choose a file
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of
On a scale of 1 to 10, how confident do you feel about your skin at the moment?
*
Not confident at all
1
2
3
4
5
6
7
8
9
Extremely confident
10
1 is Not confident at all, 10 is Extremely confident
Date
*
-
Day
-
Month
Year
Date
Save Analysis / Submit Record
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