Skincare Intake Form

YourGlowyBFF:

Skincare Intake Form

First Name *

Last Name *

Date of birth *

Postal code *

Phone *

Email *

Do you have any food, medication or product allergies?

Are you currently pregnant or breastfeeding? *

Yes

No

Wanting to get pregnant within 6 months

Do you have any current health conditions or are you being treated by a doctor? IF YES, please explain below

What are your main skincare goals right now? *

If you selected OTHER, tell me below your skin goals.

What are you currently using on your skin (AM/PM)? *

Please list any cleansers, serums, moisturizers, SPF, etc.

Have you ever had a reaction to skincare products?

BONUS OPPORTUNITY - Would you like to learn how to earn money from home sharing skincare with your friends? *

What’s your current skincare budget (monthly or per purchase)? *

How did you hear about us? *

Anything else you’d like us to know about your skin, lifestyle, or stress levels?

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