Name
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First Name
Last Name
Email
*
Phone
(###)
###
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What is your primary skin goal?
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A) Achieve a clear, blemish-free complexion
B) Reduce fine lines and signs of aging
C) Restore hydration and soothe dryness
D) Brighten and even out skin tone
E) Calm sensitivity and redness
What are your top skin concerns? (Select up to 3)
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A) Acne or frequent breakouts
B) Dullness or lack of radiance
C) Fine lines, wrinkles, or sagging
D) Redness, irritation, or sensitivity
E) Dark spots or uneven pigmentation
F) Dryness or dehydration
What kind of skincare experience are you looking for?
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A) Quick and effective, with visible results
B) Luxurious and relaxing, focused on stress relief
C) Deep cleansing and purifying
D) Hydrating and nourishing
E) Rejuvenating and anti-aging
How would you describe your skin type?
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A) Dry
B) Oily
C) Combination
D) Sensitive
E) Normal
How does your skin usually react to new products?
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A) Often sensitive; it can get red or irritated
B) Usually fine; it adapts well
C) Occasionally sensitive, but mostly okay
D) It’s resilient and rarely reacts
E) I’m not sure, but I’d like to try new treatments
How frequently would you like to get facials?
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A) Once a month for ongoing maintenance
B) Every few months, as a treat
C) Only when I have a specific issue to address
D) Seasonally to keep up with changes in my skin
E) As often as needed for relaxation and self-care
Which option best describes your lifestyle and time availability?
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A) Busy with little time for lengthy facials
B) Flexible schedule, can spend an hour or more on facials
C) Usually on-the-go, so shorter treatments are ideal
D) I love taking my time for self-care
How would you like to feel after your facial?
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A) Fresh and rejuvenated
B) Deeply relaxed and stress-free
C) Purified and cleansed
D) Hydrated and nourished
E) Glowing and radiant
If there is anything you could improve about your skin, what would it be?
*
How does your skin react to changes in weather?
*
Do you have any allergies? Please list
*
Have you ever reacted to a skincare product or ingredient? If so, please share your experience:
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How hydrated do you feel your skin is?
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Very hydrated
Somewhat hydrated
Dry
Very Dry
Have you ever had a professional treatment?
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Yes
No
Are you taking any medication?
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Yes
No
How often do you wear SPF (sunscreen)?
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Everyday, regardless of the weather.
Only on sunny days
Occasionally, when I remember
Never, I don't think it's necessary