Your First Name *Your Last Name *Date of Birth *Email *What is your skin type? a) Combination - oily in some places, dry or balanced in others: b) Dry - tight and uncomfortable, can be all over: c) Oily - shiny and glossy, can be all over: d) Balanced - no oily or dry patches How sensitive is your skin? a) not at all sensitive to skincare products b) rarely sensitive to skincare products c) sometimes sensitive to skincare products d) very sensitive and prone to redness and inflammation e) unsure What do you want your Simply Blended products to achieve for your skin? Any diagnosed medical conditions? Any prescribed medication? If yes, give details of name of medication and dosage. Any over the counter medications regularly taken? If so, which ones and how often Are you or could you be pregnant? If yes which trimester? Are you breastfeeding? What is your current skincare regime? Do you have and allergies, intolerances or sensitivities? If yes please give details Would you like therapeutic oils within your products? If yes, which type of aroma(s) so you like? a) Floral b) Wood c) Herb d) Spice e) Citrus Are there any aromas you love? Please list all Are there any aromas you dislike, please list all Do you take any Vitamin A, Carotene, or Retinol supplements? *Do you use any creams or serums which contain either vitamin A, retinol or carotene *Any other relevant information? please include as much detail as necessary Please submit to show you are happy for Simply Blended by Sarah Bennett to safely store this information in accordance to GDPR yesNameSubmit
