New Client Consultation Form

Environ Skincare Consultation
Name*

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D.O.B*

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Book your Consultation*
Your Skin

Please fill in the information below, in preparation for your consultation.
Have you got any allergies e.g Aspirin?*
Are you currently taking any prescription medication?*
Have you ever reacted to a product/treatment in the past?*
Have you recently been treated with or currently using any of the following?*

Salicylic AcidAzelaic AcidBenzoyl PeroxideAlpha Hydroxy AcidsOral AntobioticsTopical Vitamin ATopical CorticosteroidsTopical AntibioticsAny other Acne TreatmentNone of These
Have you taken Roaccutane in the last 6-12 months?*

YesNo
Are you currently pregnant or planning a pregnancy?*

YesNo
Are you currently breastfeeding?*

YesNo
Are you currently taking/being treated by any of the following?*

Blood thinning medicationHormone replacement therapyContraceptve implant/coil/injectionOral contraceptive pill
Do you smoke?*

YesNo
Have you used sunbeds in the last 6 months?*

YesNo
How would you describe your stress levels?*
Do you follow a specific diet?*

VegetarianVeganNone of theseOther
What would you like to achieve from your skincare consultation?*
Please outline details of your current skincare routine (incl. products, when you are using each product and how consistent you have been with your routine).*
How sensitive is your skin? (Tick all that apply)*

Not SensitiveSensitive to certain productsSensitive to touchSensitive to heatOther
Are you conscious about any of the following (face)?*

ScaringDullnessIrregular skin textureCongestionDark circlesAcne RosaceaPore refiningSpotssensitivitySagging/loss of elasticityUnder eye puffinessDehydrationbroken capillariesRosaceaOilinessDry lipsGeneral skin redness/blotchinessDry patchesRedness left after spotsNone of the aboveOther
Are you conscious about any of the following (body)?*

Back AcneChest AcneDry feet/cracked heelsIrregular skin textureDry skin on the bodyDry/cracked handsDry Scalp/hairNone of the aboveOther
Are you prone to any of the following conditions?*

EczemaDermatitisPsoriasisBRoken CapillariesColdsoresPoikiloderma de CivattePeri oral dermatitisNone of the aboveOther
I aim to cater for all budgets - in order to assist our recommendations it would be great if you could guide us on yours. Most Environ products last a minimum of 3 months.*

£50-£100 every 3 months£100 - £200 every 3 months£200-£300 every 3 months£300+Not sureOther
To give you accurate guidance on your skincare, I need some photographs of your bare, freshly cleansed skin. Please make sure to take photos in natural light. *

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Front facing photograph Cancelof
*

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Right side profile photograph Cancelof
*

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Left side profile photograph Cancelof
Do you give consent to add your details to my system to enable me to contact you with regard to this consultation?*

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Environ Skincare Consultation

Your Skin