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Sign In
My Account
About
Services
Products
Consultation Form
Please fill out the questions below the best you can before submitting.
Name:
*
First Name
Last Name
Email:
*
Address (to send products!)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of birth
MM
DD
YYYY
Occupation:
*
Typical availability for video chat:
*
ie. Mon. - Fri. | 9am - 5pm
What is your current morning skin care routine?
*
Cleanser, Toner, Serum(s), Moisturizer, SPF, Makeup, Other (Please include brands)
What is your current evening skin care routine?
*
Cleanser, Toner, Serum(s), Moisturizer, Other (Please include brands)
Do you use any masks?
Exfoliation, Topical Rx, Other
How does your skin feel (dry, oily, inflamed, etc—more detail the better)?
*
Do you have any skin conditions?
*
Yes
No
If yes, please include your conditions:
Do you have any allergies?
*
Yes
No
If yes, please include your allergies:
Do you have breakouts?
*
Yes
No
If yes, describe a typical breakout (placement, is it painful, how many blemishes, etc):
Do you shave your face?
*
Yes
No
What do you like about your skin?
*
What would you like to change about your skin?
*
What would you like to change in your skin care routine?
*
Describe your diet:
How much water do you drink a day (in oz)?
What is your daily sugar intake?
What is your daily gluten intake?
What is your daily alcohol intake?
What is your stress level like?
How do you manage your stress?
How many times a week do you exercise?
1-2 times a week
3-4 times a week
5-7 times a week
Not at all
How long do you exercise for?
Less than 30 minutes
30 minutes to an hour
1-2 hours
More than 2 hours
What types of exercise?
What is your routine with your skin regarding exercise?
How long do you spend outside a day?
1-2 hours
3-4 hours
5-6 hours
7-8 hours
More than 8 hours
I don't go outside
How many hours do you sleep?
3-4 hours
5-6 hours
7-8 hours
More than 8 hours
I have a really hard time sleeping
Anything else I should know??
Thank you!
