Name *

First Name

Last Name

Phone

(###)

###

####

ARE YOU:

Under 30

30-50

Over 50

WHAT IS YOUR BIGGEST SKIN CHALLENGE?

Uneven skin tone

Red and inflamed skin

Dry, itchy or flakey skin

Acne-Prone skin

Fine lines and wrinkles

None of the above I love my skin

DO YOU HAVE HYPERPIGMENTATION SUCH AS FRECKLES, MELASMA, OR SUN SPOTS?

Yes

No

I don't know

DO YOU HAVE OILY SKIN THAT IS PRONE TO BREAKOUTS?

Yes

No

I don't know

DO YOU HAVE PSORIASIS?

Yes

No

I don't know

DO YOU HAVE ECZEMA OR DERMATITIS?

Yes

No

I don't know

DO YOU HAVE ROSACEA?

Yes

No

I don't know

DO YOU HAVE SAGGING, THINNING, OR LOOSE SKIN?

Yes

No

I don't know

WHAT IS YOUR OVERALL SKIN TYPE?

Dry

Oily

Combination

Sensitive

Balanced

Unsure

WHAT IS YOUR # 1 SKIN CONCERN?

Fine lines /wrinkles

Anti-aging / prevention

Firmness/ elasticity

Dullness

Dark spots

Dark circles / Puffy eyes

Rosacea/ redness

Breakouts/ blemishes

Uneven skin tone

Oiliness/ pores

DO YOU WEAR SUNSCREEN?

Yes

No

HOW DO YOU WANT TO BUILD YOUR SKIN ROUTINE?

I want to build a routine around a product

I want to start a new routine

DID YOU KNOW USING THE SAME SKINCARE FOR A LONG PERIOD OF TIME CAUSES THE SKIN TO BECOME IMMUNE AND STOP WORKING?

Yes

No

DID YOU KNOW YOU SHOULD CHANGE YOUR SKIN REGIMEN BASED ON THE SEASONS?

Yes

No

IS YOUR SKIN SENSITIVE?

Yes

No

DAILY SUN PROTECTION IS ESSENTIAL. WHICH DO YOU PREFER?

Sheer mineral

Tinted mineral

No preference