Beautycounter Sample Request Form

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Hi! I'm so happy that you're interested in safer skincare. You deserve to feel and look your best without worrying about exposure to harmful ingredients!

Please fill out this form and I will use it to make recommendations just for you. Whether you just want to swap one item at a time or if you're ready to swap your whole bathroom, I'm here to help. All of your information will remain confidential.

Thank you for taking the time to fill out this questionnaire and I look forward to working with you!

Lauren Miller
Director with Beautycounter

First & Last Name *

Email Address *

Mailing Address (for samples to be mailed)

What is your most pressing skincare concern? *

How do you want your skin to look and feel? *

How would you describe your skin? *

Normal (none/very few blemishes, balanced)

Oily (dull or shiny complexion, blackheads and breakouts more common, larger pores)

Dry (dull or rough complexion, irritation, redness, flaky)

Combination (areas of both dry and oily skin usually along the forehead, nose, and chin)

Sensitive (trouble finding products that don't irritate the skin, redness, irritation, itchy, burning)

What is the climate like where you live? *

Do you exercise? In a gym or outdoors? *

Do you have any of the following concerns? *

acne scars

active acne breakouts (current)

dullness

dryness

general overproduction of oil

fine lines/wrinkles

aging skin

skin spots or discoloration (melasma)

eczema or dermatitis

redness or uneven skin tone

large pores

a known reaction to skincare products

Other:

Required

Do you have any known allergies or sensitivities? *

If you've had a reaction to skin care products in the past, please describe the products and symptoms you experienced.

What's your current skincare routine? Please list when you use each product (morning or night), the order of application and the brand. *

Do you prefer a minimalistic routine or are you looking for a robust daily day/night + weekly treatment routine suggestion? *

Minimalist routine

Thorough multi-step routine

I'm a little scared of a robust routine and don't really know what that entails. Tell me more..

Are you interested in cosmetics recommendations? *

Yes!

Not at this time

If so, tell me a little bit about your current makeup routine and what you're interested in replacing with a safer option. *

Please list any other concerns or questions you might have here. I'm here to support you!

Would you like to be added to my safer skincare email list? I send out skincare & wellness tips, as well as insights about how to take advantage of promotions and gifts-with-purchase! *

Yes

Not at this time

Would you like to learn about working alongside me?

Yes! I want discounted products!

Yes! I want to make money!

Tell me a little more

Not interested right now

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