Online Skincare consult

First Name *

Last Name *

Phone *

Email *

Date Of Birth *

What is your primary skincare concern? *

How does your skin feel after you wash your face? *

Are you currently using retinol? *

If yes, what percentage?

Have you used a Vitamin C before ? *

Have you experienced any skin irritation with Vitamin C products? *

If yes, Would you mind letting me know what Vitamin C products you have tried that caused irritation?

Are you prone to redness or rosacea? *

Do you experience breakouts? *

Are you pregnant, nursing or trying to become pregnant? *

Any symptoms of menopause? *

Have you been diagnosed with any autoimmune disease or disorder? *

If yes, what is it?

Do you use any tobacco products? *

Do you consume more than five alcoholic beverages per week? *

How many servings of fruits and vegetables do you consume each day? *

How often do you consume foods high in sugar? *

Are you allergic to any cosmetic ingredients, medications or food? *

Which type of regimen do you prefer? *

Please submit the selfie that you uploaded for your color match. *

Thank you for taking the time to complete this skin questionnaire. Katie and a medical professional will review your answers and evaluate your photo. Once you submit the form you will receive a text message to confirm that we have received your questionnaire. You should expect to receive recommendations within the next 24-48 business hours. We are excited to see you glow.