Kate Somerville Skin Health Experts

Personalized Skin Analysis

We are here for you! Our team of Skin Health Experts® are ready to place you on the path to beautiful skin. Each expert is a trusted professional, personally trained by Kate, here to consult with, educate and advise you. Searching for the right solution to not so perfect skin can be frustrating. We are here to listen and help determine the product and/or regimen right for you. Your glowing skin and smiling face is our success. We take pride in answering your questions and finding solutions to your concerns. Partner with us, and we promise to deliver gorgeous, glowing skin - the Kate Somerville way!

Simply answer the questions below and a Kate Somerville Skin Health Expert® will personally evaluate your confidential answers and respond with recommendations for the most effective product treatment plan for your skin concerns. You will receive an email with an attached customized Prescription Card in a PDF format file. Please provide us with answers to all the questions listed below so we can make the best possible recommendations. Your information is kept completely confidential and will never be sold or traded. This is Kate Somerville’s Privacy Policy.

* = required information

Contact Information *

DUE TO HIGH CONSULTATION VOLUME PLEASE CALL US DIRECTLY FOR IMMEDIATE ASSISTANCE.

First Name:*

Last Name:*
Address:*

City:*

State:*

Zip Code:*
Your Email Address:*

What is the best number to reach you?*

How would you prefer to receive your product recommendation results from a Skin Health Expert? (Note: Speaking with a Skin Health Expert is always recommended to ensure the most accurate recommendation possible. Please feel free to call us at
1-800-984-5283 (KATE)

How Did You Hear About Us?

Other:

Skin Health Information

1. Birthdate (mm/dd/yyyy): *

/ /

2. Your Sex is: *

3. Do you smoke?

Yes

4. Do You Have Allergies to Any Of The Following? (Check all that apply)

Aspirin	Hydroquinone	Salicyclic Acid
Retin-A	Hydrogen Peroxide	Beta Hydroxyacids
Benzoyl Peroxide
No allergies to any of the above

5.	Are you currently using any antioxidant supplements?	Yes	No
	Are you currently using any Retin-A?	Yes	No
	Are you currently using any Acutane?	Yes	No

6. Do you have any special skin problems? (Check all that apply)

I have environmentally damaged skin

I have occasional Acne

I have deep cystic Acne

I have dry skin with Acne breakouts

I have dehydrated skin

I have combination skin, dry in some places, oily in the T zone

I have oily skin all over my face

I have lines and wrinkles from natural aging

I have no special skin problems

Other:

7. What type of skin do you have?

8. What product line are you currently using?

9. What results are you looking for?( Check all that apply)

Clear up Acne eruptions

Decrease oiliness of skin

Lighten skin complexion or hyper pigmentation areas

Smooth Skin Texture

Diminish wrinkles and fine lines

Post-facial procedure or surgery skin care

Hydration

10. What do you like least about your facial skin?

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. The Skin Health Experts of Kate Somerville analyze your skin type and suggest products solely on the completeness and accuracy of the information provided by you. This is not an automated generated response to your inquiry. This is a personalized E-Mail response from one of our Skin Health Experts within 24-72 hours of sending your inquiry. If you require an immediate response, please call our toll free number at 1-800-984-KATE (5283) Monday-Friday between 9 AM and 5:30 PM PST and one of Kate Somerville’s Skin Health Experts will be happy to assist you.


© 2005-2007 Kate Somerville LLC and Skin Health Experts LLC. All Rights Reserved.