Cabelmar: The masculine cosmetics line, created with quality and efficiency

Name:
Surnames:
Address:
E-mail:
Birthday:
Post Code (C.P.):
City / Town:
Province:
Profession:
Telephone nº:

Nerve problems:	Yes	No
Do you sleep well?	Yes	No
How long do you sleep?
Do you smoke?	Yes	No
Your nourishment is:	Good	Regular	Bad
How much water do you drink everyday?
Constipation:

Suffered diseases:

Do you take medicine?

-- Skin diagnostic --

Does your skin itch?	Yes	No
Does your eyebrow desquamate?	Yes	No
Does the corner of your mouth desquamate?	Yes	No
Do you have dirty pores in your nose?	Yes	No
Do you have dirty pores in your chin?	Yes	No
Do you have wrinkles in your eye contour?	Yes	No
Do you have wrinkles in the corner of your mouth?	Yes	No
Does your skin tend to suffer from rashing?	Yes	No
Do you have dryness in your cheeks?	Yes	No
Do you suffer from acne or do you have acne scars?	Yes	No
Do you have skin dull color brilliant aspect?	Yes	No
Do you have rough skin and without any kind of sheen?	Yes	No
Do you have sheen skin in nose and chin?	Yes	No
Do you have normal or dry cheeks?	Yes	No
Do you have wrinkles in all your face?	Yes	No
Do you have wrinkles in your neck?	Yes	No

   How often do you shave?
   Do you suffer from rashing after shaving?                Yes    No
   If there are other observations no indicated above but you consider that they are important for us to know, please indicate.

Cabelmar has at your service a special page where you can consult or ask us any doubt you may have. Please do not hesitate to contact us for further information. Our address and timetable are:

   Address:
        Cosmética Cabelmar
        C/ Valencia, 4
        Tf.: 902 190 478
        03150 - Dolores (Alicante)

   Timetable:
        For Monday to Friday
        Mornings: From 10.00 a.m. to 14.00 p.m.
        Evenings: From 16.00 p.m. to 20.00 p.m.

Please take note that we commit ourselves to answer all your questions in a 48 term, working day as long as your data has been filled in properly.