Virtual Skincare Consult with Priscilla

Virtual Skincare Consult with Priscilla

Hello! Welcome to my Virtual consultation form. Fill out the form below as detailed as possible, so I can access your skin and skincare and recommend the best products 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
Which gender do you identify as?*
Age*

18-2425-3940-5455+
SKIN DIAGNOSIS
What's your skin type?*

Oily SkinDry SKinNormal SkinCombination Normal to OilyCombination Normal to Dry
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
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)*

Fine lines and lack of toneDeep lines and lack of firmnessLoss of firmnessLoss of radianceVisible/enlarged poresOily skinShiny T-zone (forehead, nose & chin)Congested skin (pimples, blackheads etc.)Dry, tight feelingDry with flaky patchesI have no other concernsOther
What is your current skincare routine (select all that apply)*

Eye make-up removerFace washCleanserTonerHydrating essenceSerumFacial oilEye creamMoisturiserExfoliator/polish/scrubFace maskOther
List ALL Your Skincare Products with their Brand name you are currently using and HOW YOU USE THEM. It's Important to tell me how you are using them*
Give me a details of your skin and anything you feel I should know?*
Attach Image of your facial skin: Picture 1*

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Attach Image of your facial skin: Picture 2

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Should be Empty:

Virtual Skincare Consult with Priscilla

SKIN DIAGNOSIS