Perfect Blue Alchemy Facial Skin Consult
After you fill out this form, we will contact you to go over details and discuss with you how we can help. If you have any questions or concerns, please email us at customerservice@perfectbluealchemy.com or you can direct message us on Instagram - www.instagram.com/perfectbluealchemy
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Email *
Are you new to us? *
Are you happy with your skin? *
What do you think your skin type is? *
Do you currently or have you had any of the following skin issues?
Current
Past
Pimples & Breakouts
Cystic Acne
Eczema
Dry Patches
Redness
Rashes
Razor Bumps
Boils
Acne Scars
Discoloration/Hyperpigmentation
Psoriasis
Rosacea
Other
If you answered Other previously - please explain further
How long have you experienced any of the skin issues you checked off above? *
Do you have any other health issues, medicines or dietary needs that you feel affect your skin condition?
Contact info
Your name *
Phone number *
E-mail *
Preferred contact method *
Required
Questions and comments
Perfect Blue Alchemy Facial Skin Consult
This form and any and all information discussed in consultation via email, phone or social media is kept strictly confidential. Contact information is never shared, copied or transferred. Perfect Blue Alchemy retains all rights to the voluntarily provided information herein. The information collected here is only used to provide general skincare information and is not used to medically assess, diagnose or treat any conditions directly. The Perfect Blue Alchemy Facial Skin Consult form or resultant skincare consultation cannot be used in lieu of appropriate medical consultation and treatment.
© 2019 by Perfect Blue Alchemy LLC
A copy of your responses will be emailed to the address you provided.
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