Tailored Skincare Questionnaire

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Name *

Which skincare tier are you selecting? *

Bronze

Silver

Gold

How many products would you like? *

Autre :

How old are you? *

I AM...

Male

Female

Prefer not to say

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What are your top skin goals?

If you are currently using any active ingredients (e.g.. Retinol) please state below. *

My skin in the sun *

Sun burns easily, rarely tans. Light skin and most likely has freckles.

Rarely has freckles, can and does tan in summer

Olive skin, easily tans in summer. Can sit in the sun without protection for around 45 mins before burning

Can safely sit in the sun for around 1 hour. Dark brown skin

Can sit in the sun for around 80 mins, Dark brown to Black skin.

I would describe my skin as

Very dry

Dry

Oily

Combination (dry and oily)

Autre :

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My sensitivity

Hyper-sensitive

Sensitive

Insensitive

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when I wake up my skin feels

Dry and tight

Stressed and painful

Dry in some areas

oily

Oily in the T-zone

Normal

Autre :

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In the evening my skin feels

Very dry

Dry

Oily everywhere

Oily in the T-zone

Dry in some areas

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I would like to get rid of

Pimples

Clogged pored (blackheads)

Dullness

Inflamed and sore pimples

Flaking skin

Fine lines and wrinkles

Broken capillaries

My problem areas

Are you pregnant? or breastfeeding?

Yes

Maybe

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If there are specific products you would like (toner etc) then please type below

Lifestyle

I smoke

I drink alcohol

I eat a lot of sugar

I eat a lot of junk food

I am exposed to excessive amounts of blue light (light from my laptop, phone etc)

I fly frequently (more than 4 times per year)

I live in a busy city

I am stressed frequently

I drink coffee frequently

I get less than 4 hours sleep per night

I get 8 or more hours sleep per night

I get ample sleep per night

Please state any brands, products or ingredients you dislike.

Please state any personal preferences, such as only vegan products or only cruelty free products.

I have a skin allergy *

I believe that I may currently have a form of acne. *

Yes

Maybe

I am currently seeing a dermatologist? *

Yes

Email *

Do you agree to the Terms and Conditions stated below? *

Yes

Terms and Conditions

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