Name of who invited you ___________________________________________________________________________Name ___________________________________________________________________________Address ___________________________________________________________________________

City ___________________________________________ State_____ Zip _____________

Phone # _______________________ Email ______________________________________

What is the #1 reason you came today?

___________________________________________________________________________

Do you currently use skincare products? Yes _____ No _____

Do you currently wear cosmetics? Yes _____ No _____

Your age: <25 years 26-35 years 36-45 years >46 years

How would you describe your skin? Normal Dry Oily Combination Reactive/Sensitive

How much do you spend on skincare products per month? <50 50-150 151-200

201-350 351-500 >500

Is taking care of your skin a priority?

Yes No

Check the type of products that you are currently using on a daily basis- Make up remover Cleanser Toner Serum/Treatment Moisturizer Eye Cream Face sunblock Body sunblock Body lotion

Do you or someone you know have concerns with the following?

CHECK THE FOLLOWING THAT FIT: You Name of Family or Friend

Concerns:Excess oil ______ ______________________________Dry flakes ______ ______________________________Dryness ______ _______________________________Dull, lack lustre ______ _______________________________ Brown spots, uneven skin tone ______ ______________________________Fine lines and wrinkles ______ _______________________________Acne/breakouts ______ _______________________________ Eye area- puffiness/dark circles ______ _______________________________Eye area- dry ______ _______________________________Eye area- lines and wrinkles ______ _______________________________ Digestive Health (Acid, reflux, Ulcers, IBS, Colitis, etc.) ______ _______________________________ Interested in slowing down the aging process (inside) ______ _______________________________Interested in Wellness and Nutrition products _______ _______________________________

Which do you prefer? A skincare range with elaborate products (ie: many products to be applied on

different parts of the face) A skincare range with very few products(ie: faster and simpler application) I don't have a preference, so long as it works

Where do you usually purchase your skincare products? Salon/Spa Department Stores Dermatologist, skin specialist or clinics Internet Drug Stores

Which type of Event would you be Interested in hosting? Beauty 101 Event Custom Blend Foundation/Powder Clinic Skin Care 101 Clinic Wellness 101 Event