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
City	State / Province
	Country

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 .

Keep me in the loop! I'll pass
I'm here because

I want to relax I want results I want information I have a gift voucher Don’t really know
My skin feels

Comfortable & balanced Sensitive & irritated Dry & tight Flaky & rough Oily & bumpy
The following concerns me about my skin:

Breakouts / acne Excessive oil / shine Uneven tone Wrinkles / fine lines Black / white heads Sun damage Rosacea/eczema / dermatitis Dull / dry
I currently use the following products:

Cleanser Eye cream Toner Day moisturiser Mask Night cream Make-up Exfoliator Serum Sunscreen Shower gel Body lotion Soap Self-tan lotion
I'm currently using these skincare brands:
I'm also using:

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

Cosmetics AHAs Medicine / drugs Fragrance Nuts Latex Sunscreens Iodine Animals Plants / Flowers
I have had hair removal in the past 6 weeks:

Shaving Stringing Tweezing Laser Electrolysis Depilatories Waxing
I have been in the sun in the last 24 hours:

Yes No
I have exfoliated my skin within 48 hours: (scrub or chemical)

Yes No
I have exercised today:

Yes No
I am, or there’s a chance I could be, pregnant:

Yes No
I’m going through menopause or HRT:

Yes No
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?

Yes No Yes, 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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