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Name
*
First
Last
objectives: conditions? Number:
Cell Number:
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Email
*
Age:
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Which skincare centre are you situated at?
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How does your skin respond in the sun?
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— Select Choice —
Painful redness/ blistering/ peeling – My skin goes red very quickly and then I peel.
Turns red then turns brown/tan brown Easily – My skin goes red and then I get slight tanning.
Skin goes very dark – I rarely go red and get a tan quickly.
My skin doesn’t change when I go into the sun – I never burn and my skin goes darker very quickly.
Please Indicate if you have any of the following skin disorders:
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— Select Choice —
Rosacea
Eczema
Psoriasis
Skin sensitivity / reactivity to topical products
Auto-immune skin disorders
Skin cancer history
None
If you have a Skin Disorder, what topical skincare products (prescription or non-prescription) are you using to address these conditions?
Please indicate your skincare objectives:
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— Select Choice —
Improve my acne/ problematic skin.
Reduce pigmentation/ dark marks. on my skin
Reduce the appearance of lines/ wrinkles and sagging skin.
Improve my skin texture and complexion evenness.
Keep my skin looking good and avoid early ageing.
Other
Other skincare objectives:
Please indicate your skin type:
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— Select Choice —
Combination skin
Oily skin
Dry skin
Sensitive skin
Which Lamelle products are you currently using, if any:
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