Please answer these questions as best as you possibly can. This will help us determine the best skincare regimen for your needs.

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* 1. Todays Date

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* 2. Email

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* 3. First and Last Name

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* 4. History of Allergies (Please List any/all known allergies- i.e medication, food, cosmetic products, seasonal, pets)

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* 5. Do you have any serious health conditions known to effect your skin? Please List (please list any injuries, surgeries as well):

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* 6. Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements)

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* 7. Questions Related To Your Skin Health. Please Select Your Concerns:

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* 8. Drink Alcohol? How often?

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* 9. Smoke? 

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* 10. Stress Level (1 being the lowest, 10 being the highest)

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* 11. What is your current diet like per week? (5 being highest intake) *

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* 12. Have you ever had Botox®, Juvederm®, or any other injectables? Have you had chemical peels, microderms or permanent makeup?

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* 13. How is the overall health of your nails? (brittle, healthy, etc)

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* 14. How is the overall health of your hair? (dry, oily, dryness of scalp, etc)

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* 15. Do you have any other concerns of your skin on your body that are different from the skin on your face? (dry patches on arms, itchiness, etc)

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* 16. Follow a special diet? (Vegan, vegetarian, restricted diet) please explain: 

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* 17. What is your current skin care routine (products, etc)?

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* 18. Do you buy your skin care products from a conventional store currently or through a professional?

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* 19. Do you tend to go for more natural products or medical grade products for your skin?

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* 20. When it comes to your current skincare routine, what do you feel you need help with the most (i.e product recommendations, how to use products, having enough time, etc)

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* 21. Are you open to recommendations today to better your skin and wellness program?

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* 22. I did not sign up for my three free skincare tips for healthy glowing skin, and I would like them please!

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