My Beauty Lift
Getting to know YOU
Name (Optional)
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First Name
Last Name
Email Address (Optional, will be added to The Beauty Cue Tips Newsletter)
example@example.com
Phone Number (Optional)
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Please enter a valid phone number.
1. What is your age range?
20's
30's
40's
50's+
60's
70's
80+
2. What is your biggest concern about your skin?
Acne
Pores
Aging
Dark spots
Dullness
Wrinkles
Dark circles
Redness
Saggy Skin
Other
3. What type of skin do you have?
Oily
Dry
Combination
Saggy
Other
4. How often do you feel that your skin is sensitive?
Never
Rarely
Sometimes
Always
6. Do you feel stressed about how you look and feel?
Yes
No
7. How much time do you spend in front of electronic devices per day?
Less than 1 hour
1-3 hours
3-6 hours
6-10 hours
More than 10 hours
8. Do you experience any of the following medical conditions?
Eczema
Allergies
Rosacea
Other
9. What type of weather do you experience where you live?
Sunny & Tropical
City dweller
Cold winters & mild summers
Dry & hot desert
Cold & dry year-round
10. How much time do you spend to take care of your skin per day?
Less than a minute
A few minutes
Around 5 minutes
More than 7 minutes
11. How do you wash your face?
Just water
Water and a foaming cleanser
Water and an oil based cleanser
Other
12. How often do you workout?
Never
1-2 times a week
3-5 times a week
6-7 times a week
2x times a day
13. Are you interested in our weight management? If so, I will send information on our NeoraFit.
Yes, please text to me.
Not right now
14. What condition is your hair in?
dry/brittle
highlighted
Receding Hairline
Hair thinning
15. Are currently on medication and your research shows a side affect is hair loss?
Yes
No
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