Environ Skincare Consultation
Name
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First Name
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E-mail
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Phone Number
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D.O.B
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Book your Consultation
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Your Skin
Please fill in the information below, in preparation for your consultation.
Have you got any allergies e.g Aspirin?
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Are you currently taking any prescription medication?
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Have you ever reacted to a product/treatment in the past?
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Have you recently been treated with or currently using any of the following?
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Salicylic Acid
Azelaic Acid
Benzoyl Peroxide
Alpha Hydroxy Acids
Oral Antobiotics
Topical Vitamin A
Topical Corticosteroids
Topical Antibiotics
Any other Acne Treatment
None of These
Have you taken Roaccutane in the last 6-12 months?
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Yes
No
Are you currently pregnant or planning a pregnancy?
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Yes
No
Are you currently breastfeeding?
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Yes
No
Are you currently taking/being treated by any of the following?
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Blood thinning medication
Hormone replacement therapy
Contraceptve implant/coil/injection
Oral contraceptive pill
Do you smoke?
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Yes
No
Have you used sunbeds in the last 6 months?
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Yes
No
How would you describe your stress levels?
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Low
Medium
High
Do you follow a specific diet?
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Vegetarian
Vegan
None of these
Other
What would you like to achieve from your skincare consultation?
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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).
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How sensitive is your skin? (Tick all that apply)
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Not Sensitive
Sensitive to certain products
Sensitive to touch
Sensitive to heat
Other
Are you conscious about any of the following (face)?
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Scaring
Dullness
Irregular skin texture
Congestion
Dark circles
Acne Rosacea
Pore refining
Spots
sensitivity
Sagging/loss of elasticity
Under eye puffiness
Dehydration
broken capillaries
Rosacea
Oiliness
Dry lips
General skin redness/blotchiness
Dry patches
Redness left after spots
None of the above
Other
Are you conscious about any of the following (body)?
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Back Acne
Chest Acne
Dry feet/cracked heels
Irregular skin texture
Dry skin on the body
Dry/cracked hands
Dry Scalp/hair
None of the above
Other
Are you prone to any of the following conditions?
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Eczema
Dermatitis
Psoriasis
BRoken Capillaries
Coldsores
Poikiloderma de Civatte
Peri oral dermatitis
None of the above
Other
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.
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£50-£100 every 3 months
£100 - £200 every 3 months
£200-£300 every 3 months
£300+
Not sure
Other
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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Browse Files
Front facing photograph
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Browse Files
Right side profile photograph
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Browse Files
Left side profile photograph
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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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