Beautycounter Sample Request Form
Please complete this form so I can customize your sample needs.

*If you have not taken the skincare quiz yet, start here:

Make sure you have the results sent to your consultant "Hayden Smith" at the end. That will prompt me to put your samples together.
Email address *
Your name *
Your answer
Street Address: *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
What is your Instagram handle?
Your answer
What best describes you? *
What are you most interested in? *
Which regimen did the skincare quiz recommend for you? (see link to quiz in introduction above)
Is there a man in your home that would benefit from safer products and would be up for sampling our CounterMAN regimen?
Which other best sellers are you interested in trying?
Anything else I should know as I put your request together? (i.e. allergies, sensitivities, concerns, or feel free to share about your current skincare routine or products you are using)
Your answer
Have you ever considered joining our mission in a more meaningful way as a consultant?
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