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New Client Skin Care Questionnaire

If you are a new client, please fill out the form below so we can create a personalized skin care plan customized for you. Once you submit the form, it usually takes less than 1 business day to get a response, but it can take as long as 2 business days. All plans are created exclusively by Justine Taylor, RN.

Please provide the following information for the person this Skin Care Plan is for:

First Name:

Last Name:

Please Enter your email address so we can notify you when your Skin Care Plan is finished:

If you would like easy access to your customer information, including the ability to quickly reference past orders and/or Skin Care Plans you can assign a password to your account (optional):

Confirm Password:

1. How old are you?
2. Are you male or female?
Male
Female
3. If you could change or improve something about your skin what would it be?
4. What skin care products do you currently use?
5. What type of skin do you have?
Dry (facial skin is very dry)
Oily (entire face is very oily)
Combination (t-zone tends to be oily)
Normal
6. Do you have acne?
Yes
No
7. If you have acne how would you characterize the severity?
Mild (red bumps and pustules that come & go)
Moderate (red bumps and pustules that come & go)
Severe (presistent nodules & cysts that are resistant to treatment)
N/A
8. Are you currently taking accutane?
Yes
No
9. Have you been diagnosed with rosacea or psoriasis?
Rosacea
Psoriasis
No
10. Do you have any of the following skin conditions?
Enlarged pores
Blotchy or uneven pigment
Saggy facial skin
Fine lines around eyes and mouth
11. Are you pregnant?
Yes
No
12. Do you have any medical conditions or experience any allergic reactions to products?
13. Is there any other information that might be helpful to know about you?
14. Please provide your telephone number so that I can call you with any questions.
15. Please tell us how you heard about Healthy Skin by Design, we would love to know!
 
 
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