Congratulations on making the first step to achieving clearer, healthy skin. The following questionnaire will provide the information that we need to develop a skincare regime that will meet your individualized needs. Answering the following 6 questions will take approximately 1 minute to complete.

Question 1:

We would like to begin by getting to know you a little better.

First Name : 

Email : 

---

Question 2:

Please choose the option that best describes your present skin type.

  Oily

  Dry

  Normal

  Combination

---

Question 3:

Please indicate your present skin concerns (Can choose more than one)

  Acne

  Blackheads/Whiteheads

  Roughness/Uneven Feeling

  Acne scarring (red or brown spots left over)

Question 4:

Would you classify yourself as having sensitive skin?

  Yes

  No

  I'm not sure

---

Question 5:

How often do you experience a "break-out"?

  Everyday

  Once a week

  Once a month

  Never

---

Question 6:

Is there anything that you feel makes your skin look worse? (Can choose more than one)

  When I get my period

  When I'm stressed

  When I wear makeup

  When I don't get enough sleep

  After I work out

  I don't feel that any of these events affect my skin

---

I would like to receive special offers from Clear Choice Skin Care
  YES       NO