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Custom Skin Care Form

Step 1 of 7

14%

Name
First Last
Birth Date
Date Format: MM slash DD slash YYYY
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

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*
Comments
This field is for validation purposes and should be left unchanged.

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