Skin Consultation Form

Skin Consultation Form

Please tell us a little about your skin so we can treat your skin and accomodate to the best of our ability.
Your Full Name
Date of Birth
Postal/ Zip Code

Street Address

Street Address Line 2

CityState / Province
Phone Number
Format: 0000000000.
E-mail
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I'm here because

Other
My skin feels

Other
The following concerns me about my skin:

Other
I currently use the following products:

Other
I'm currently using these skincare brands:
I'm also using:

Other
Before you start my treatment, you should probably know the following:
I have had allergic reactions to:

Other
I have had hair removal in the past 6 weeks:

Other
I have been in the sun in the last 24 hours:
I have exfoliated my skin within 48 hours: (scrub or chemical)
I have exercised today:
I am, or there’s a chance I could be, pregnant:
I’m going through menopause or HRT:
I have an illness or disease:
I am currently taking the following medication:
Is there anything else we should know about your skin health or overall health?
Are you comfortable with us documenting a part of your treatment for social media?
I’ve read and completed this form truthfully and to the best of my knowledge.
I understand withholding or providing the wrong information may result in irritation.
Your signature below
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