Skin & Tonic Skin Consultation
Your Personal Details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date Of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Skin & Medical Consent
it is really important not to exclude any medication you are taking.
medication: are you currently taking any medication prescribed by a gp or any other practitioner?
not on medication
on medication, please include medication names in the option below
Other
Medication: Are you currently taking any medication containing vitamin A?
No
Yes please include details in the box below
Other
Pregnancy: Are you currently pregnant, planning pregnancy or breastfeeding?
Not pregnant
Planning Pregnancy
Pregnant please include weeks below
Other
Other Conditions: Are you attending any GP or other practitioner for any other conditions?
no
yes please include details in the box below
Other
Allergies: Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?
no
yes please include details in the box below
Other
Rate your stress levels
1
2
3
4
highly stressed
What is your skin type?
Dry (Eg Tight, dull & Flakey)
Oily (Eg Breakouts, Blackheads & Shiney)
combination (Eg Dry Cheeks, Oily T-Zone)
Normal
What are your main skin concerns?
Wrinkles
Enlarged Pores
Pigmentation
Fine Lines
Acne
Rosacea
Uneven Skin Tone
Scarring
Redness
Other
Do you have a history of the following?
Smoking
Sunbeds
Other
Are your prone to or currently have the following?
Eczema
Psoriasis
Rosacea
Herpes Simplex (coldsores)
Other
Do you get any of the following?
Blackheads
White Heads
Cystic Acne option 3
Occasional Spots option 4
Hormonal Breakouts
Do you have regular periods
yes
no
What products are you looking for (Or Recommended)
Eminence Organic Skincare
Environ
Advanced Nutrition Programme
Jane Iredale Make Up
What is your current routine?
Pre cleanse
Cleanse
Toner
Exfoliate
Mask
Moisturizer
Eye cream
Spf daily
What products are you currently using?
Concerns & Queries
Main ConcernsTell us about your main concerns at the moment
Skin GoalsTell us about your main concerns at the moment
Please attach photos of your skin, close up of any skin concern/ areas of concern
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