Please take a moment and complete this form as accurately as possible. I will then enter the data into the Personal Beauty System program and issue a printout of the results for you to review. I will then ask for your feedback on the information provided. This will help me determine whether I should pursue purchasing the program for continued use.

Once you have confirmed the data and transmitted, please do not use the "return to website" button. It will not bring you back to this page. Use a navigation link in the left column to continue around this site.

Personal Identification Information
First Name
Last Name
Address
Zip Code
Gender
Home Phone
Birth Month & Day: (mm/dd)
Cell or Work Phone
Email
Age
Under 25
26 - 35
36 - 45
Over 45
Skin Type
Dry
Normal
Normal plus Oily T
Oily
Skin Condition
None
Sensitive Skin
Rosacea
Adult Acne
Hyperpigmentation
Broken Capillaries
Face: Concerns
None
Dull Skin
Uneven Skin Tone or Blotchiness
Enlarged Facial Pores
Age Spots on Face
Deep Creases (Forehead or Crow's Feet)
Fine Lines and Wrinkles Around Eyes
Dark Circles Under Eyes
Lips (Fine Lines, Dry, Lipstick Feathering)
Sagging Facial Skin
Loss of Firmness/Elasticity
Hand/Body: Concerns
Cellulite
Loose Abdominal Skin or Sagging Buttocks
Age Spots on Hands
Breast Stretch Marks or Sagging
Stretchmarks
Allergies
Fragrance
Fruits: Tropical
Fruits: Citrus
Lanolins
Nuts
Current Regimen
Toner? Yes No
Separate Night Moisturizer? Yes No
Exfoliant? Yes No
Daily Facial UV Protection? Yes No
Which best describes your customer's product usage?
Prefers to use a minimal amount of products, and would like to see a Basic product regimen of 3 products.
Would like to see a Complete product regimen of all products and treatments most appropriate.
Which of the following are important when deciding which skincare products to use?
Natural Ingredients
Cutting-edge technology
Anti-aging benefits
Products for my skin type
Beautiful packaging
At-home dermatological treatments