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Cosmetology form

1. Name *

2. Age:

3. E-mail address *

4. Skin type *

dry

oily

combination

normal

5. Main problem

skin discoloration

acne vulgaris-ascertained by a dermatologist

rosacea-ascertained by a dermatologist

sensitivity

seborrheic dermatitis-ascertained by a dermatologist

atopic dermatitis-ascertained by a dermatologist

psoriasis-ascertained by a dermatologist

allergies to cosmetic ingredients, which ones?

wrinkles

capillaries

blackheads/whiteheads

dry skin

overproduction of sebum

Do you take any medications / dietary supplements? If yes, write down the names of the drugs

6. Describe your morning and evening skincare routine. Write down the exact name and the brand of the product along with INCI composition. Products without the INCI composition given will not be included in the skincare routine plan. *

Example:
Evolve Organic Beauty - Hyaluronic Eye Complex

Skład: Aqua (water), Aloe Barbadensis Leaf Water*, Glycerin*, Cucumis Sativus (Cucumber) Fruit Extract*, Sodium Hyaluronate, Polianthes Tuberosa Extract, Aloe Barbadensis Leaf Juice Powder*, Amorphophallus Konjac Root Powder, Sodium Levulinate, Sodium Dehydroacetate, Potassium Sorbate, Sodium Anisate, Citric Acid, Sodium Benzoate.

7. What bothers you about your skincare? Is there something you want to work on? *

8. Do you need any specific kind of product?

toner

day cream

night cream

face wash

makeup remover

serum

I would like full new skincare routine

9. Is there any active ingredient / product you want to include in your skincare routine? *

10. Do you get any professional treatments/facials on your face? If yes, what kind of treatments? How often do you get them and when was the last treatment? Are you planning on getting one? *

11. Do you go to a dermatologist? If yes, describe the treatment scheme. *

Are you pregnant?

Do you breastfeed?

Are you undergoing oncological treatment?

Other

12. How do you know about this inquiry?

Facebook - write WWW address

Instagram - write WWW address

Website - write WWW address

Blog - write WWW address

YouTube - write WWW address

Recommendation

Other

13. In order to prepare the individual skincare routine plan for you we need to get to know your skin and see what it needs. Please attach a few photos of your skin (nose, forehead, chin, cheek) preferably in good quality and taken in the daylight without makeup. (max 5mb) *

Consent to the processing of personal data.

I agree to the processing of my personal data in the survey provided by Janusz Lis who runs a business under the name Janusz Lis Proseller.pl, ul. Skoroszewska 24, office 3, 02-495 Warsaw, address for service: ul. Jutrzenki 177, 02-231 Warsaw in order to provide a cosmetic consultation service. Please be advised that you can withdraw your consent at any time without affecting the lawfulness of data processing before its withdrawal. In order to withdraw this consent for data processing, please send an email to kontakt@cosibella.pl. Expressing consent is completely voluntary but necessary to perform the service. If the consent is not expressed, it is not possible to conduct a cosmetic consultation.

Thank you for completing the survey.

Our cosmetologist will contact you in 5 business days.

Best Regards Sklep Cosibella.pl.

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