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Custom Skin Care Form
Step 1 of 7
14%
Name
First
Last
Birth Date
Phone
Allergens/Irritants
Health Issues
Medications, if any
Skin Type (Pick a selection)
*
Pale white skin, blond or red hair, blue eyes, freckles always burns never tans often Scandinavian, Celtic or Northern European descent.
Fair skin, blond or red hair, blue, green or hazel eyes usually burns, tans minimally often Western/Central European descent.
Cream to olive skin, fair to medium with any hair or eye color sometimes burns then tans easily often Eastern European or Mediterranean descent.
Light to moderate brown, brown or black hair and eyes rarely burns always tans well often Middle Eastern, Hispanic/Latin American, West Asian, Native American or North African descent.
Dark brown skin, hair and eyes very rarely burns tans very easily typically African, South Asian, Caribbean/South Pacific Islands, South American descent.
Deeply pigmented dark brown to darkest brown skin, hair and eyes never burns, tans very easily same descent as above.
Various Skin Issues (Check all that apply)
*
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other
Eyes
Wrinkles
Puffiness
Dark circles
Other
Skin Tone
1
2
3
4
Various Skin Combinations
Dry
Tight
Contracted
Thin
Refined small Pores
Oil
Prone to dark spots
Hyperpigmentation
Uneven skin tone
Prematurely aging
Have you seen an esthetician?
Yes
No
If yes what was said of the issue at hand
Have you seen a dermatologist?
Yes
No
If yes what was said of the issue at hand
What type of product are being sought after?
*
Cleanser
Moisturizer
Scrub
Facial Masque
Toner
Serum
Other
Other Information
Email
*
Email
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