KC Skin Studio Consultation form
KC Skin Studio is a ladies only salon. If you would like to make an appointment please WhatsApp Karen on 0877923969 after you fill out the form. A €20 booking fee is required. Please include as much information about your skin along with close up pics. Once I get your WhatsApp text I’ll get back to you as soon as I can and can recommend a treatment and can give some available dates.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of birth
*
-
Day
-
Month
Year
Date
How did you hear about us?
*
Further details on checked box
Do you have any allergies or any medical concerns? Please explain.
*
Are you taking any medication? Please list.
*
Do you suffer from any of the following?
*
Hormone condition
Skin condition
Auto immune condition
Asthma
Cancer
Claustrophobia
Depression
Arthritis
Hay fever
Cold sores
Histamine reactions
Diabetes
Hepatitis
Poor wound healing
Metal pins and plates, metal teeth implants
Renal insufficiency
Pacemakers
Hyperthyroidism
Serious vascular disorders
Epilepsy
Endocrine syndromes
Any medical condition that desensitises the skin
Cuts bruises and abrasions
Blood disorders (such as anaemia or use of blood thinners)
Rosacea
Sensitive skin
Keloids
None of the above apply
Please give details on boxes checked
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Do you smoke
*
Yes
No
Are you using any of the following?
Acids
Vitamin A/Reinol
Topical corticosteroids
Acne treatments
Sunbeds
Self tan on face or neck
Vitamin supplements
What are your main skin concerns?
*
Acne
Acne Rosacea
Rosacea
Fine lines
Wrinkles
Loss of firmness
Pigmentation
Dull skin
Enlarged pores
Scarring
Crows feet
Dark circles
Tell me a little about your skin ie is it dry, oily, sensitive, dehydrated, prone to breakouts etc
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What is your skin type?
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Dry (tight, dull, flaky)
Oily (shiney, blackheads, large pores)
Combination (dry cheeks, oily t-zone)
Normal (balanced and smooth)
I don’t know my skin type
Do you ever get breakouts?
*
Please list your current skincare products. Cleanser, toner serums, exfoliator etc. **this section cannot be left blank**
*
Are you happy with your current skincare and are you seeing results?
*
Do you have any of the following?
*
Cough
Fever
Feeling unwell
Cold or flu like symptoms
Coldsore
None of the above apply
Please add a close up clear picture of your skin WITHOUT MAKEUP on, looking straight at the camera.
*
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Please add picture looking to the side.
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Please add a picture looking to the other side.
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Booking Policy A €20 booking deposit is required to secure your appointment.The deposit comes off your treatment when you attend.If you cancel or reschedule at ANY time, the deposit is lost.A new €20 deposit is required to book again.Cancellations within 48 hours incur a €40 fee.No-shows incur an €80 fee.
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Notes (office use only)
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