MBP Consultation Form
First Name
Last Name
Email
Phone/Mobile
Age
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What is your skin type?
Oily
Dry
Combination
Sensitive
Normal
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What are your primary skin concerns? (Select all that apply)
Acne
Fine lines & wrinkles
Dark spots & pigmentation
Redness or rosacea
Dryness or flakiness
Enlarged pores
Dullness
Sensitivity
Other (please specify)
Please specify
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Do you have any known skin conditions or allergies? (e.g., eczema, psoriasis, etc.)
Yes
No
Please specify
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Describe your current skincare routine.
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What is your skincare routine frequency?
Twice daily
Once daily
A few times a week
Occasionally
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Water intake:
- Select -
Less than 1 liter
1-2 liters
More than 2 liter
Sun exposure:
- Select -
Minimal
Moderate
High
Sunscreen use:
- Select -
Daily
Sometimes
Rarely or never
Stress levels:
- Select -
Low
Moderate
High
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Do you have specific ingredients you prefer to use or avoid in skincare products?
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What are your main goals for this consultation?
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Is there anything else you'd like us to know about your skin or lifestyle?
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Submit and proceed to make payment
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