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Consultation Form

First name*

Last name*

Date of Birth*

Email*

Phone*

Yes, add me to your mailing list.

Do you drink alcohol?

Yes

No

If Yes, how often?

Do you smoke?

Yes

No

If Yes, how often?

Medical Information

DO YOU CURRENTLY HAVE OR BEEN TREATED FOR:

ACNE

DEPRESSION

SKIN DISEASE

HIGH BLOOD PRESSURE

COLD SORES

DIABETES

CANCER

ROSACEA (REDNESS)

HAVE YOU USED ACCUTANE WITH THE PAST YEAR?

Yes

No

LIST ANY RECENT RESURFACING PROCEDURES (INCLUDING MICRODERMABRASION) OR SURGERIES (INCLUDING COSMETIC)

LIST ALL MEDICATIONS YOU ARE TAKING

LIST ALL KNOWN ALLERGIES

ARE YOU PREGNANT OR NURSING?

Yes

No

ARE YOU ALLERGIC TO ASPIRIN?

Yes

No

Skin care Information

AVERAGE STRESS LEVEL (1 Low- 10 High)

1

2

3

4

5

6

7

8

9

10

HOW DO YOU FEEL ABOUT THE QUALITY OF YOUR SKIN? ( 1 Bad - 10 Very Good

1

2

3

4

5

6

7

8

9

10

DO YOU WEAR SUNCREEN?*

YES

NO

PLEASE LIST ANY VITAMINS OR SUPPLEMENTS YOU MAY BE TAKING:

HOW OFTEN DO YOU EXERCISE? Please describe

HOW MUCH WATER DO YOU DRINK DAILY?

WHEN WAS YOUR LAST SUNBURN?

WHEN IN THE SUN, DO YOU BURN?

ALWAYS

USUALLY

SOMETIMES

RARELY

VERY RARELY

NEVER

DESCRIBE YOUR SKIN TYPE

NORMAL

SENSITIVE

DRY/DEHYDRATED

NOT SURE

OILY

ROSACEA

ACNE/ACNE PRONE

WHICH SKIN CONDITIONS ARE YOU MOST CONCERNED ABOUT?

WRINKLES

DARK SPOTS

DULLNESS

OILINESS

ACNE

ACNE SCARRING

REDNESS

DRY/ROUGHNESS

PIGMENTATION

OTHER:

WHAT IS YOUR CURRENT SKIN CARE ROUTINE? PLEASE LIST PRODUCT NAMES AND REGIMEN

WHAT DO YOU LIKE ABOUT YOUR SKIN?

WHAT DON'T YOU LIKE ABOUT YOUR SKIN?

Contact

Callus on : 0333 335 6139

or drop us an email for any enquiry.

Name

Phone

Email

Message

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