First Name *

Last Name *

Phone *

Email *

1. Do you notice fine lines or wrinkles on your skin? *

A) Yes, frequently

B) Occasionally

C) Rarely

D) Not at all

2. Have you experienced a loss of firmness or elasticity in your skin? *

A) Yes, significantly

B) A little

C) Not much

D) Not at all

3. Is your skin often dry or dehydrated? *

A) Very often

B) Sometimes

C) Rarely

D) Never

Do you have age spots or uneven skin tone? *

A) Yes, quite a few

B) A few

C) Just a couple

D) None at all

5. Have you noticed an increase in dullness or lack of radiance in your skin? *

A) Yes, noticeably

B) Slightly

C) Rarely

D) Not at all

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