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. 1YOUR DETAILS2MEDICAL DETAILS3SKIN DETAILS4SKINCARE ROUTINE NAME First Last EMAIL PHONE MEDICAL CONSENTAre you currently taking any medication prescribed by a GP or any other practitioner? Yes No If yes please please provide further information:Are you currently taking any medication containing vitamin A? Yes No If yes please please provide further information:Are you currently pregnant, planning pregnancy or breastfeeding? Yes No If yes please please provide further information:Are you attending any GP or other practitioner for any other conditions? Yes No If yes please please provide further information:Do you have any allergies? E.g. Aspirin, allergies to ingredients in products? Yes No If 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 Lines Wrinkles Enlarged Pores Pigmentation Acne Redness/Rosacea Scarring Do you have a history of the following? Smoking Sunbeds How sensitive would your skin be? Mild Moderate Very Sensitive Not Sensitive Are your prone to or currently have the following? Eczema Psoriasis Rosacea Herpes Simplex Do you get any of the following? Comedones/Blackheads Pustules/White Heads Cystic Acne Occasional Spots Hormonal Breakouts Never Breakout SKIN ROUTINE What is your current skincare routine? Please complete each section below.CLEANSE TONER MOISTURISER MASK EYE CREAM What 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)Max. file size: 80 MB.