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PERSONALIZED SKINCARE RECOMMENDATION FORM
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Personal Details
Name
*
First
Last
Email Address
*
Phone Number
*
Basic Information
Age Range
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Skin Type
*
Oily
Combination
Dry
Normal
Not sure
Are you currently pregnant or breastfeeding? (Optional)
Yes
No
Prefer not to say
Skin Concerns
*
Acne / Breakouts
Dark spots & hyperpigmentation (melasma, sunspots, post-acne marks)
Uneven skin tone
Sensitive skin / Irritation
Dry or flaky skin
Oily skin / Excess shine
Aging skin / Fine lines
Textured skin
Stretch marks
Other (please specify)
(Select all that apply)
Tell Us More About Your Skin
*
Your Current Routine (Optional but helpful)
Products you're currently using
Have you used any of these before?
Retinol / Adapalene
Vitamin C
AHAs / BHAs (e.g., glycolic acid, lactic acid, salicylic acid)
Azelaic Acid
None
Upload Photos (Optional but highly recommended)
Please upload clear photos for an accurate assessment. Close-up of concern areas
(Your photos and personal information remain private and secure.)
Additional Notes (Optional)
Allergies
Sensitivities
Medications
Hormonal changes
Lifestyle factors (e.g., sweating, sun exposure, stress)
(You can tick more than one)
Anything else you’d like us to know
Submit
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