Skin Consultation Free Skin Consultation Please complete the following Online Skin Consultation form and one of our consultants will review it and contact you. Please note that any information you supply will be treated in the strictest confidence. 1 YOUR DETAILS2 MEDICAL DETAILS3 SKIN DETAILS4 SKINCARE ROUTINE NAME First Last EMAIL PHONE MEDICAL CONSENTAre you currently taking any medication prescribed by a GP or any other practitioner?YesNoIf yes please please provide further information:Are you currently taking any medication containing vitamin A?YesNoIf yes please please provide further information:Are you currently pregnant, planning pregnancy or breastfeeding?YesNoIf yes please please provide further information:Are you attending any GP or other practitioner for any other conditions?YesNoIf yes please please provide further information:Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?YesNoIf yes please please provide further information: SKIN QUESTIONNAIRE Please tick the appropriate box(s) below:What is your skin type?Dry (e.g. tight, dull & flakey)Oily (e.g. Breakouts, blackheads & shiny)Combination (e.g. dry cheeks, oily T-zone)Normal (e.g.balanced & smooth)What are your main skin concerns?Fine LinesWrinklesEnlarged PoresPigmentationAcneRedness/RosaceaScarringDo you have a history of the following?SmokingSunbedsHow sensitive would your skin be?MildModerateVery SensitiveNot SensitiveAre your prone to or currently have the following?EczemaPsoriasisRosaceaHerpes SimplexDo you get any of the following?Comedones/BlackheadsPustules/White HeadsCystic AcneOccasional SpotsHormonal BreakoutsNever Breakout SKIN ROUTINE What is your current skincare routine? Please complete each section below.CLEANSETONERMOISTURISERMASKEYE CREAMWhat are your skincare goals and what would you like to achieve?Please upload an image for a member of our team to analyse your skin (images should be less that 1 MB)
