What's your skin type? Your type depends on things such as: 1. How much water is in your skin, which affects its comfort and elasticity 2. How oily it is, which affects its softness 3. How sensitive it is *


 
What are your highest priority skin concerns? *


 
How would you rate the regularity of your current skincare regimen? *






 
What are the skincare products you use regularly/have used? *


 
What are some challenges you have in maintaining a skincare regimen?


 
What are your current favorite skincare products that you love? *

Please list Brand & Product Name!
 
What products are you in the market for now? *

Ex. Vitamin C serum to help with acne scarring, enzyme exfoliation, a nice anti-aging eye cream, etc...
 
How often do you travel in a month? *

 
About You

The information you provide will remain confidential and will only be shared with our board certified dermatologist to develop a customized treatment plan for you.
 
What is your full name? *

 
What is your gender? *




 
Your birthday? *

 
Genetics can play a role in skin problems affecting tone and appearance. Knowing your background can help us better customize a treatment plan. *


 
Do you have any known allergies?

     
 
Are you a smoker?

     
 
Are you pregnant?

     
 
Have you ever been on Accutane?

     
 
Are you allergic to any specific ingredients? *

If there aren't any known allergies, are there bad experiences you've had with active ingredients like a chemical peel, etc...
 
Are you on Retin-A, Retinol, Tretinoin, or other antibiotics to treat severe acne or other skin condition? *

 
What's your address, including zip code? *

Weather, climate, and seasonal changes dictate how much moisture your skin needs to maintain a healthy glow!
 
Anything else we didn't cover in the quiz, but you'd like to share so we can tailor the best regimen for you? Please order your kit here: https://belle-iq.myshopify.com/products/winter-skin-survival-kit-pre-order

Ordering the kit is an important last step!
 
Would you be interested in testing new products with us? We constantly source new emerging indie skincare brands. If so, let us know!

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