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
E-mail
Would you like to receive occasional the email update and our latest special offers? We promise we don't spam, it's not our style .

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I'm here because

I want to relaxI want resultsI want informationI have a gift voucherDon’t really knowOther
My skin feels

Comfortable & balancedSensitive & irritatedDry & tightFlaky & roughOily & bumpyOther
The following concerns me about my skin:

Breakouts / acneExcessive oil / shineUneven toneWrinkles / fine linesBlack / white headsSun damageRosacea/eczema / dermatitisDull / dryOther
I currently use the following products:

CleanserEye creamTonerDay moisturiserMaskNight creamMake-upExfoliatorSerumSunscreenShower gelBody lotionSoapSelf-tan lotionOther
I'm currently using these skincare brands:
I'm also using:

Botox / Restylane / CollagenRetina-A / Renova / Adapalene / Hydroxyl Acid / Retinol / Vitamin AAcne medicationOther
Before you start my treatment, you should probably know the following:
I have had allergic reactions to:

CosmeticsAHAsMedicine / drugsFragranceNutsLatexSunscreensIodineAnimalsPlants / FlowersOther
I have had hair removal in the past 6 weeks:

ShavingStringingTweezingLaserElectrolysisDepilatoriesWaxingOther
I have been in the sun in the last 24 hours:

YesNo
I have exfoliated my skin within 48 hours: (scrub or chemical)

YesNo
I have exercised today:

YesNo
I am, or there’s a chance I could be, pregnant:

YesNo
I’m going through menopause or HRT:

YesNo
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?

YesNoYes, but please keep me anonymous
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.
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