SIRCUIT®SKIN CONSULTATION
First Name:
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Last Name:
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Emai
l
:
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Phone:
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Message:
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How can we help you? Do you have any special concerns?
Zip Code:
*
How did you hear about us?
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What is your age?
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18-25
26-35
36-45
46-55
55 & Over
What's your skin type?
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Normal - Overall good skin condition that is not dry or oily or sensitive.
Combination - Cheeks feel comfortable while T-zone feels oily.
Dry - Face feels dry and tight and could appear flaky or rough in patches.
Oily - Cheeks and T-zone are oily with enlarged pores and prone to blemishes.
Sensitive - Skin is easily irritated and can have skin redness.
What are your primary skin concerns? (check all that apply)
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Age Prevention
Fine Lines & Wrinkles
Loss of Firmness & Elasticity
Dehydration
Acne l Blemish Prone
Hormonal Breakouts
Hyperpigmentation
Redness & Irritation
In terms of your eye area, what are your key concerns? (check all that apply)
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Dark Circles
Fine Lines & Wrinkles
Deeper Lines l Crow's Feet
Hydration
Under Eye Puffiness l Bags
Protection & Age Prevention
What skin care products do you currently use on a daily basis? (check all that apply)
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Cleanser
Serum
Toner
Daily Moisturizer
Nighttime Moisturizer
Eye Care Product
Exfoliants l Peels
Blemish Treatment
Mask
Body Moisturizer
Do you have known allergies to ingredients? If so please specify.
*
Are you under the care of a dermatologist or doctor for any skin condition on your face?
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Are you currently using any topical or oral prescriptions for the face? If so, what prescriptions?
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Are you pregnant or nursing?
*
Submitted successfully!
Your submission has been received. Thanks for your time!
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