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Skincare Consultation Form – Ime Site
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About Us
Skincare Consultation - New
Personal Information
Name
(Required)
First
Last
What is your age?
(Required)
Phone Number
(Required)
Email Address
(Required)
Preferred Contact Method
(Required)
Phone
Email
Text
Skin History
What is your primary skin concern? (Check all that apply)
(Required)
Fine lines & wrinkles
Acne or breakouts
Dryness or flakiness
Redness or sensitivity
Hyperpigmentation (dark spots)
Dullness
Other
Select All
Other
(Required)
How would you describe your skin type?
(Required)
Oily
Dry
Combination
Normal
Sensitive
Unsure
Do you have any diagnosed skin conditions?
(Required)
Rosacea
Eczema
Psoriasis
Dermatitis
Other
Other
(Required)
Have you had any cosmetic procedures (e.g., Botox, fillers, chemical peels, laser treatments)?
(Required)
Yes
No
If yes, please list and date:
(Required)
Environmental & External Factors
How much sun exposure do you get daily?
Minimal
Moderate
High
Do you wear sunscreen daily?
Yes
No
If yes, what SPF?
(Required)
What climate do you live in most of the year?
Humid
Dry
Moderate
Do you work indoors or outdoors?
Indoors
Outdoors
Availability for Scheduling Meetings
What Day(s) is good to meet? (Select all that apply)
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select All
What time between 11:00 AM and 4:00 PM EST time is good for you?
(Required)
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
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