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Registration Form
First Name
Last Name
Birthday
Code
Phone Number
Email Address
Where would you like to chat with your skin expert?
Your skin goals include:
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Required
Hydrated and shiny skin
Improved elasticity
Reduce fine lines and wrinkles
Reduce hyperpigmentation and dark spots
Rejuvenation
Reduce redness
Balance excess oil
Decrease the appearance of enlarged pores
Improve skin texture
Reduce dark circles
Skin formations
You prefer a skin care routine that is:
Skin care budget (lv/month)
Skin Type
Eye Colour
Occupation
Recreation time
Do you experince any side effects such as burning, stinging or redness when trying new and different skincare products?
Do you drink about two litres of liquids per day?
Do you drink more than two cups of coffee per day?
Does your face feel tight after washing?
Does your face feel tight when NOT applying hydration?
Does your face look shiny and greasy after applying foundation?
Does your face feel/look oily in the morning?
How many times a day do you wash your face with a cleansing product?
Do you regularly use SPF when exposed to sunlight?
When exposed to sunlight your skin gets:
Do you smoke or vape?
Are you aware of any hormonal changes you may be going through due to pregnancy, menopause, thyroid condition, etc.?
Do you consume lactose?
Do you consume refined sugars?
Have you received any of the following skin therapies ?
Oxygen therapy
AHA peel / glycolic acid, malic acid, tartaric acid, mandelic acid, citric acid
BHA peel / salicylic acid
Azelaic acid
Dermabrasion
Micro-needling
Laser resurfacing
Botox
Fillers
List any diagnosed medical conditions (including skin conditions).
List all allergies that you have or suspect you might have.
List all medications you are currently taking.
Do you have anything to add?
Submit
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