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First Name

Age

What is your skin type?

Oily

Dry

Normal

Combo

Sensitive

Acne-Prone

# of products you prefer to use?

1-3

4-6

7-9

10+

Condition of your eyes?

Puffy

Under-eye bags

Dark circles

Fine lines

Sagging

Fatigue

Type of climate:

Dry

Humid

Cold

How often do you exfoliate?

Rarely

Once per month

Once a week

Two times per week

3-4 times per week

Everyday

Which is more important to you?

Effective products

Green products

Vegan products

How often do you wear sunscreen?

Country?

Add'l notes? Allergies/sensitivities?

Gender

Male

Female