Full Name
Email
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Phone
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1. How would you describe your skin type?
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Oily
Dry
Combination
Sensitive
2. What are your top skin concerns? (Select all that apply)
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Fine lines & wrinkles
Acne or breakouts
Dark spots or hyperpigmentation
Uneven skin tone or texture
Dryness or dullness
3. How often do you exfoliate your skin?
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Every day
A few times a week
Once a week
Rarely or never
4. Have you ever had a chemical peel before?
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Yes, and I love them!
Yes, but I had a bad reaction.
No, but I’m interested.
No, and I’m nervous about it.
5. Do you experience breakouts or acne regularly?
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Yes, I struggle with acne.
Occasionally, but not too bad.
No, I rarely get breakouts.
6. How sensitive is your skin?
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Very sensitive – I react to a lot of products.
Somewhat sensitive – I have to be careful.
Not sensitive at all – I can handle strong treatments.
7. Do you use any of the following skincare products? (Select all that apply)
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Retinol or prescription retinoids
Vitamin C serum
AHAs/BHAs (glycolic acid, salicylic acid, etc.)
Hydroquinone or skin-brightening products
None of the above
8. Have you had Botox, fillers, or laser treatments recently?
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Yes, within the last 2 weeks.
Yes, but over a month ago.
No, I haven’t had any of these treatments.
9. How much time can you commit to post-peel recovery?
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A few days – I don’t mind light peeling.
A week – I want great results but need to plan ahead.
I can’t handle any downtime right now.
10. Would you like a free skin consultation to discuss your results?
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Yes, I’d love expert advice!
Maybe, I want to learn more first.
No, I’ll decide later.