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Welcome to Healthy Skin by Design - Jan Marini Skin Care Products and Professional Skin Care Consultations
Jan Marini

Personalized Skin Care

Please fill out the form below so we can create a personalized skin care plan that works 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.

Your Full Name:                     
Your Email Address*:           
Your Telephone Number::    (optional)

How old are you?

Are you male or female?

What are your skin care goals in general?

What skin care products do you currently use during the day?

What skin care products do you currently use at night?


How would you describe your skin?

Do you have acne? Yes No

If so, how severe is your acne?

Have you used Accutane within the past 6 months? yes no

Have you ever been diagnosed with Rosacea? yes no

Have you ever been diagnosed with Psoriasis? yes no

Do you have enlarged pores? yes no

Are you noticing saggy or lax facial skin and/or neck skin? yes no

Are you noticing fine or deep lines around your mouth and eyes? yes no

Do you have blotchy uneven pigment on your skin? yes no

How much time are you willing to commit to the care of your skin on a daily basis at home?

What medications are you currently taking? (please list)

Are you currently pregnant or nursing? yes no

Describe any medical conditions for which you are receiving treatment?

Is there any other information you can tell us that might be helpful in creating a skin care package for you?

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