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* 1. Name, Phone# and/or IG Handle

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* 2. Is your skin...

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* 3. Do you have any of the following? (Check all that apply)

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* 4. What don’t you like about your skin? And what would you like to fix?

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* 5. Do you have any allergies? (If yes, specify in the space below)

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* 6. What products are you using now?

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* 7. Questions/Concerns?

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