Personal Details
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
How did you heard about us?
Instagram
Facebook
Google Search
Friend/Family Referral
Other
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Medical History
Tick all that apply
Pregnancy or breastfeeding
Allergies or sensitivities
Recent sun exposure or tanning
Autoimmune diseases
Medication
Other
Please give more details about anything you ticked above (e.g. medication name, allergy, condition):
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Skin Type & Routine
How would you describe your skin type?
Dry
Oily
Combination
Sensitive
Normal
Not Sure
Do you use any skincare products?
Yes
No
If yes, please list them
Do you use SPF daily?
Yes
No
Are you currently using any active ingredients like retinol, acids, or vitamin C?
Yes
No
If yes, please specify.
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Lifestyle Factors
Do you work mostly indoors or outdoors?
Indoors
Outdoors
Both
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
How many hours of sleep do you get on average per night?
Please Select
Less than 5
5-7
7-9
9+
How would you rate your stress levels?
Low
1
2
3
4
High
5
1 is Low, 5 is High
Do you exercise regularly?
Yes
No
If yes, please specify type and frequency.
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Treatment Goals & Concerns
What are your main skin concerns?
Acne
Fine lines/wrinkles
Dryness
Hyperpigmentation
Redness
Enlarged pores
Other
What are your primary goals for treatment?
Improve skin texture
Hydration
Anti-aging
Brightening
Clear acne/acne scaring
Other
Have you had any previous aesthetic treatments?
Yes
No
If yes, please specify which treatments you have had and how long ago:
Are there any treatments you want to avoid?
Yes
No
If yes, please specify.
Photo Upload
Please upload makeup-free photos of your face in natural lighting (optional but helpful)
Front, left side and right side
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Budget & Frequency
What is your approximate budget for treatment?
Please Select
£50 - £100
£100 - £200
£200 - £300
£300 +
How often would you like to receive treatments?
Weekly
Every 2 weeks (fortnightly)
Monthly
Occasionally
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Additional Information & Consent
Anything else you'd like to share about your skin or health?
Preferred Contact Method
WhatsApp
Phone call
Text message
Email
Would you like to receive updates, promotions, or special offers from us?
Yes, I'm happy to receive updates.
No, I do not wish to receive marketing messages.
I confirm that the information provided is accurate. I consent to Amber MediSpa using this information to create my personalised treatment plan. I understand treatment results may vary and agree to follow aftercare instructions.
*
I agree
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