Pediatric Skincare Consultation Form

Parent/Guardian Information

Email

Phone number

Parent/Guardian name

Enter full name

Child's Information

First name

Enter full name

Child's Age

Enter Child's exact age in years or months

Gender

Female

Male

Neutral

Child's Skin Concerns

What are your child's primary skin concerns? (Check all that apply)

Add all that apply and click"other" to specify additional skin concerns

Allergies and Sensitivities

Does your child have any known allergies? If yes, please select below:

Food Allergies

Environmental Allergies

Other

Enter any additional allergens or skin concerns

Has your child ever experienced any adverse reactions to skincare products?

Are there any specific ingredients that irritate your child's skin?

Are there any natural products that you have used on your child's skin that may have caused irritation?

Current Skincare Routine

What products are you currently using on your child's skin?

How often do you wash your child's face?

Do you use any sunscreen on your child?

How often does your child bath or shower?

Does your child participate in any sports or activities that involve sweating?

Does your child have any skin conditions, such as eczema or psoriasis?

Eczema

Psoriasis

N/A

Other

Select all that apply

Additional Information

What are your goals for your child's skin?

Are there any specific concerns or questions you'd like to discuss?

Consent

Consent Signature

Authorize Anneka's Butter LLC to review consultation form.

I authorize Anneka's Butter to use the information provided in this form to create a personalized skin care plan for my child. I understand that this information will be kept confidential and used solely for the purpose of providing my child with tailored skincare recommendations.