Representative ID:________

Receive a Personalized Skin Care Recommendation from Deborah Hunter

Create Your Beauty Profile Today

Name (please print): ____________________________________________

Address: ______________________________________________________

City: ______________________________ State: ______ ZIP: __________

Phone – Work: _____________________ Other: ______________________

What is the best way to contact you? (Circle one)

Email Phone Visit

Birthday: __/__ (mm/dd)

Skin Profile

Age (circle one) Under 25 26-35 36-45 Over 45

Skin Type (circle one)

Dry Normal Normal plus oily T-Zone Oily

Face: Skin Concerns (circle all that apply)

None Dull Skin Uneven skin tone or blotchiness Enlarged facial pores

Age spots on the face Deep creases (Forehead or crow’s feet)

Fine lines and wrinkles around eyes Dark circles under eyes

Lips (Fine lines, dry, lipstick feathering) Sagging facial skin

Loss of firmness / elasticity

Skin Conditions (circle all that apply)

None Sensitive Skin Rosacea Adult acne Hyperpigmentation

Broken capillaries

Allergies (circle all that apply)

None Fragrance Fruits: Tropical Fruits: Citrus Lanolins Nuts

Hand & Body: Concerns (circle all that apply)

Cellulite Loose abdominal skin or sagging buttocks Age spots on hands

Breast stretch marks or sagging Stretch marks

Current Skin Care Regimen

Do you currently use:

Toner: yes / no Separate Night: yes / no

Exfoliant: yes / no Moisturizer: yes / no Daily UV: yes / no

Which best describes your product usage?

Prefer to use a minimal amount of products, and would like to see a Basic product regimen of 3 products.

Would like to see a Complete product regimen of all products and treatments most appropriate.

Which of the following are important when deciding which Skin Care products to use? (circle all that apply)

Natural Ingredients Anti-aging benefits Beautiful packaging

Cutting-edge technology Products for my skin type

At-home dermatological treatments

Representative ID: _________