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Skin Assessment Form

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New? Join Our Family & More Than 700+ Active Users

Because we sell medical-grade cosmeceutical skincare products, all online customers are required to complete our online assessment. If this is your first time buying products with active ingredients or any of our online products, you’ll need to complete our one-time online assessment and set up an account.

Name

Your Name Your Surname

Contact Number

Email Address

Date of Birth

MM slash DD slash YYYY

Password

Enter Password Confirm Password

Do Any Of The Conditions Below Apply To You?(Required)

Pregnant

Planning to fall pregnant

Breastfeeding

Lupus erythematosus or any autoimmune illnesses

Active eczema/ rosacea or allergy-prone skin

Excessive daily sun exposure

Oral acne medication such as Roaccutane/Acnetane or Oratane or any prescription topical treatments.

None of the above

Sorry, due to your selection, we are unable to continue. However, we want to help you. Please contact our skincare specialist on (021) 983 5948, so that we can recommend products that are made for your skin. We look forward to hearing from you.

What Is Your Sex?(Required)

Female

Male

What Is Your Age?(Required)

5-10

15-20

25-30

35-40

45-50

60-70

What is your skin condition(Required)

Normal Skin

Sun Damaged skin

Dry Skin

Oily skin

Uneven Skin Tone

Pigmentation

Sensitive skin

Blemishes

Early ageing/ fine lines and wrinkles

Acne

Deep Wrinkles

Please confirm that the information you have provided is accurate and has been completed to the best of your knowledge*(Required)

I confirm that I have completed the form personally.

Please confirm you have filled out this assessment personally*(Required)

I confirm that I have completed the form personally.

I acknowledge if I purchase any products not recommended by MD DermOutlet staff I will be doing so at my own risk.(Required)

I acccept

Welcome to our family and thank you for taking the time to complete the skin assessment/registration. Recommendations will be displayed after you submit the form and you will be able to buy any product via our online store.

Phone

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Why Choose Us

Located in Cape Town and shipping all over the country

Quality Products

We are experts in the treatment of various skin diseases and can offer related products

Free Delivery

We offer various delivery options, and free shipping, on orders over R750.

Secured Payments

Fast, secure and reliable payment options via EFT, debit, and credit cards for all banks.

Top-Notch Support

We offer the highest quality dermatology consultations, treatments, and skin surgery.

Talk To Us 24/7

Have Questions?

If you have any, we want to hear from you.

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Terms & Conditions
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Our Story
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Terms & Conditions
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Our Story
Contact Us

Terms & Conditions
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Our Story
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