Client Intake Form

First Name

Last Name

Email Address

Phone

Please Select Your Preferred Service

Fresh Start

Radiance Revival

Ultimate Rejuvenation

Age Range

Occupation

Gender

State

Location

Country of residence

Skincare Routine: Please list all the skincare products you currently use and their brand names

Do you have allergy or medical condition that requires you to avoid any skincare product/ingredient?

Yes

Are you pregnant or breastfeeding

Yes

Not Applicable

Are you currently taking any medication that may affect your skin?

Yes

Not Sure

Please select any preferences or restrictions you may have for the skincare products you use?

Cruelty Free

Vegan

I do not have any restrictions

Fragrance Free

Other

Is there anything else you would like us to know about your skin or skincare concerns

Kindly upload a well lit picture capturing your face, neck and other problem area. Please note that the picture should not be more than 2days old.

Choose Images

As a skincare consultant, my job is to provide you with advice and recommendations to help you achieve your skincare goals. However, it is important to understand that I am not a dermatologist and as such, cannot give any sort of medical diagnosis or prescribe any medication. Do you wish to continue with this process?

Yes

After the consultation, we will recommend skincare formulations without specifying any particular brand. To guarantee authenticity and confirm that products with the recommended formulations are purchased, we require that you make the purchase from us.

Our aim is to avoid situations where clients react adversely to a product formulation or refuse to purchase the complete recommended formulations, subsequently complaining that our recommendation did not work.

However, if you choose to purchase the skincare formulations independently, we can provide you with specified brands for an additional cost of N10,000. Do you still wish to proceed with this process, keeping these terms in mind.

Kindly note that this is only for Nigeria Clients, Brand recommendation is included in the consultation fee (paid in dollars) for clients outside Nigeria. Please select the option 'Not applicable' if you are outside Nigeria.

Do you still wish to proceed with this process, keeping these terms in mind.

Yes

Not Applicable

Please input your full name as your signature below