Skin Care Consultation Survey

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Thank you for requesting your complementary skin care consultation!

My name is Cindy Gapinski and I am really looking forward to helping you with your skin. Please answer the questions below.

As you will see from the questions below, great skin involves more than just using great products.

Please make sure that your email address is correct, otherwise your personal skin care advice cannot be returned to you.

I value your privacy and will never share or sell your personal information posted in this form.

I will be in touch shortly and look forward to helping you with your skin!

Cindy Gapinski

NOTE: Unfortunately, I can only help customers residing within the United States (50 states only, no territories or provinces). Please do not expect a response if you live outside of the US. Sorry for the inconvenience.

First Name *

Last Name *

Email *

Age Group

I'm experiencing these skin symptoms: Please check all that apply.

Extremely blemished skin

Occasional blemishes

Very oily skin

Oily skin

Oily skin only over my nose and forehead

Normal skin - no oil, no dryness

Dry skin

Dry skin everywhere but my nose and forehead

Extremely dry skin

Red blotches of dry skin

Extremely sensitive skin

Mildly sensitive skin

Enlarged Pores

Blackheads

Whiteheads

Skin Discoloration or Uneven Skin Tone

Please detail any other information that might help me understand your skin type better.

What skin care products are you currently using?

Have you seen results from using these products?

Yes

Clear selection

Is your skin showing signs of aging?

Yes

Clear selection

If yes, what aging signs do you have? Please check all that apply.

Sagging skin over cheeks

Sagging skin on neck

Baggy eyes

Fine lines

Age spots or liver spots

Deep lines around mouth or eyes

Crows feet around eyes

Loss of firmness

Other

Please detail any other aging signs you would like help with.

Do you have scars?

Yes

Clear selection

How often do you wear sunscreen?

Never

Occasionally

Only when I'm going to be outside a long time

Every time I go outside regardless of the length of time

Everyday - I moisturize with sunscreen

Clear selection

Have you always used sunscreen this much?

No, I used to never wear sunscreen

No, I used to always wear sunscreen

Yes, I use sunscreen the same amount now as I did years ago

Clear selection

If you could change one thing about your appearance, what would it be?

To receive a phone consultation enter your phone number including area code

What is your time zone?

Eastern

Central

Mountain

Pacific

Alaska

Hawaii

Clear selection

What is a convenient time to call? Example: Monday - 7 to 9 pm

How would you rate your current diet?

Junk food addict

Health food nut

Clear selection

How much water do you drink a day?

Several glasses

A couple of glasses

I drink some if I remind myself

I don't drink water at all

Clear selection

Please rate your stress level

Not stressed at all

Super stressed

Clear selection

What is your primary goal in talking with a skin care consultant?

Do you live within the US?

Yes

Clear selection

Submit

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