Skincare Consultation Form
In order to personalise your skin consultation please complete the following consultation form and submit in advance of your consultation.
Name
*
Post code
*
Phone number
*
Format: 00000000000.
Email address
*
example@example.com
I am currently using or have used Accutane (isotretinoin) in the last six months
*
Yes
No
I am pregnant or nursing/lactating
*
Yes
No
I have allergies
*
Yes
No
I have a skin infection/open wound in the treatment area
*
Yes
No
I am allergic to aspirin (acetylsalicylic acid)
*
Yes
No
I have been exposed to the sun or used a tanning bed in the last 3 weeks
*
Yes
No
I am currently using sunless tanning products
*
Yes
No
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
*
Yes
No
I am using prescription topical medications at this time
*
Yes
No
I have previously experienced an adverse reaction to skincare products
*
Yes
No
If you answered YES to any of these, please explain further
What is the ethnic background of your parents?
*
Do you have any medical issues?
*
Are you currently on any form of restricted or weight loss diet?
*
Yes
No
What is the main reason for your enquiry today?
*
Which of these statements is most applicable to you?
*
I would like to look better for my age
I would like to change something that has been bothering me
I would like to look more attractive
Have you had an aesthetic consultation or treatment before?
*
Yes
No
How often do you think about having an aesthetic treatment?
*
Most days
Weekly
Monthly
When I think about my appearance, I feel | look- Please tick three
*
Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive
On a scale of 1 - 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your appearance?
*
On a scale of 1 - 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
*
After treatment I would like to feel - Please tick three
*
Fresher
Happier
Brighter
More awake
More youthful
Slimmer
More attractive
More illuminous
More confident
What are your main skin concerns?
*
When did you first notice your concern?
*
Which of these apply to your skin?
*
Lines (superficial)
Wrinkles
Decreased volume
Loss of elasticity (saggy skin)
Glycation (criss-cross wrinkles)
Dryness
Blackheads
Whiteheads
Cysts (boils)
Acne Scarring
Sallow (yellow/dull) complexion
Oiliness
Open pores
Hyperpigmentation (brown spots)
Hypopigmentation (white spots)
Uneven skintone
Freckles
Broken capillaries
Inflammation
Redness
Sensitivity
Do you notice your skin concern gets worse at any time of the day/month/year?
*
What is your current skincare routine?
*
How is your current skincare helping your skin?
*
Are there any specific products you would like to try?
*
Which of these in-clinic treatments interest you?
Skincare
Chemical Peels
IPL
Microdermabrasion
Facials
Dermaplaning
Skin Tightening
Micro-needling
Mesotherapy
Laser
Brow Lift
Eyelid Lift
Fat reduction Chin
Capillary Removal
Laser hair removal
Thread vein removal
Skin Rejuvenation
Fat reduction injections
Transformational Facials
Plasma Fibroblast Skin Tightening
Skin Needling
Permanent Make up
Microblading
ACP Blemish Removal (skin tags, seborrheic keratosis, thread veins etc...)
Tattoo Removal
Hair Growth Scalp Treatments
How did you hear about us?
*
My doctor
Adverts
Recommendation
Search engine
Social media
Previously Visited
Preferred contact details
*
Phone:
Email:
SMS
What does your skin look like now?
Please read the guide below and provide a photo so we can assess your skin
Take Photo Front:
OR Upload File from phone or PC
Take Photo Right:
OR Upload File from phone or PC
Take Photo Left:
OR Upload File from phone or PC
Signature
*
Thank you for completing this Consultation Form.
We look forward to discussing your skin goals at your personal consultation.
Would you like to receive further marketing such as new products & treatments as well as special promotions? Please note that you can unsubscribe at anytime and we do not share your details with any other 3rd party
*
Yes
No
Submit
Should be Empty: