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PERSONAL CONSULTATION
 

UV GEL would like to know about your individual beauty concerns. Please complete the Beauty Questionnaire below and press the click here button when completed. One of our Beauty Experts will customize a UV GEL skin care program especially for you. You will receive your program by return mail to the address you indicate.

 

Name
Address
City       State/Province
Country       Postal Code
Telephone       Email


Under 25 45-54
25-34 55-64
35-44 65 or older


Eye puffiness Dark circles Expression lines
Wrinkles Broken capillaries Dry skin
Irregular texture Pigmentation marks Other    


AM:
PM:


    Exfoliators
    Masks
    Accutane
    Retin A
    Alpha Hydroxy Products


Pore size Small Medium Large
Breakouts Never Once a month More
Appearance Dull medium shiny
Texture Fine Normal Coarse
Blackheads Nose Cheeks Chin
Sensitivity Frequent Occasional Rarely
Your untreated skin feels Tight, dry Slightly dry Comfortable
Your skin type Highly sensitive Dry/Delicate Normal/Dry
Normal/Oily Oily


Level of stress High Medium Low
Smoker Yes No
Sunbather Frequently Occasionally Never
Outdoor sports and activities Yes No
Travel Frequently Occasionally Seldom


To submit your form:
 
 


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