Regimen Counter

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Please describe your skin concerns and what your skin goals are* This field is required.
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Large
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Small
Ok
Ok
4
What is your skin type?* This field is required.
Normal/Combo
Dry
Oily
Acneic
Sensitive
5
What products are you currently using and how often? Please list product name and brand.* This field is required.Example: Cerave Gentle Cleanser everyday AM/PM Glymed+ Retinol Rejuvenation Serum 3x/week PM Nars Liquid Foundation everyday
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Large
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Small
Ok
Ok
6
Do you have any known allergies or sensitivities to certain products?* This field is required.Example: Benzoyl Peroxide, CBD
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Large
Normal
Small
Ok
Ok
7
Please upload a clear, up close image of your face so our esthetician can properly analyze your skin.* This field is required.Please be sure to have adequate lighting and cleansed skin
8
Please verify that you are human* This field is required.
Should be Empty:

Regimen Counter