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Skin Analysis Form

 

Please fill out the following form so that I can determine the best products for your skin, and send samples. 

Please provide as much information as possible in all fields, with as much detail as you can.   This helps me to determine the best producst for your skin type.   (you cannot provide too much information).   You can type as much information as you want in each field.

All fields marked with a * are compulsory.           Your details will never be shared with any other party. 

Thank you for taking the time to fill out this form.

* Required fields
Name *
E-mail Address *
Address (to send samples) *don't forget suburb & postcode! *
Phone *
Mobile Phone:
How did you hear about us? (please name "friend" or specific website) *
Your Age *
Smoker * no
yes - regular
yes - occasional
What products do you currently use (eg: Avon Cleanser, La Prarie moisturiser, toner, exfoliant, mask etc) *
How do you describe your skin and/or skin problems? *
What concerns you in particular?
Are you on any medication (prescription or otherwise)?
How much water would you drink per day?
Do you have any allergies or particularly "sensitive" skin? *
What do you cleanse with? Does it feel tight after cleansing?
Is your skin/T-zone oily during the day or at the end of day?
Do you wear make-up regularly?
How is the skin on your body, hands & feet?
Would you like any PARTICULAR samples sent?
Any further comments?
Do you want: * skin analsysis & samples in the mail
skin analysis by email (no samples)

I have read and agree to the Privacy Policy *

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