AlumierMD x Jotform Consultation Form 2021

Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Mobile / Home Telephone
Email address
example@example.com
I am currently using or have used Accutane (isotretinoin) in the last six months

YesNo
I am pregnant or nursing/lactating

YesNo
I have allergies

YesNo
I have a skin infection/open wound in the treatment area

YesNo
I have been exposed to the sun or used a tanning bed in the last 3 weeks

YesNo
I am allergic to aspirin (acetylsalicylic acid)

YesNo
I am currently using sunless tanning products

YesNo
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®, Duac, Benzoyl Peroxide)

YesNo
I am using any prescription topical medications at this time

YesNo
I am using AHA & BHA products

YesNoUnsure
I have used skincare products that caused an adverse reaction

YesNo
If you answered YES to any of these, please explain further
Which skincare brand are you using?
What is the ethnic background of your parents?
Do you have any medical issues?
What is the main reason for your enquiry today?
Which of these statements is most applicable to you?

would like to look better for my agewould like to change something that has been botheringwould like to feel better overall in my skinwould like to have clearer skin
Have you had an aesthetic consultation or treatment before?

YesNo
How often do you think about having an aesthetic treatment?

Most daysWeeklyMonthly
When I think about my appearance, I feel | look- Please tick three

DullTiredSadAngryOldFreshHappyBrightUnattractive
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

FresherHappierBrighterMore awakeMore youthfulSlimmerMore attractiveMore illuminousMore confident
What are your main skin concerns?
When did you first notice your concern?
Which of these apply to your skin?

Lines (superficial)WrinklesDecreased volumeLoss of elasticity (saggy skin)Glycation (criss-cross wrinkles)DrynessBlackheadsWhiteheadsCysts (boils)Acne ScarringSallow (yellow/dull) complexionOilinessOpen poresHyperpigmentation (brown spots)Hypopigmentation (white spots)Uneven skintoneFrecklesBroken capillariesInflammationRednessSensitivityAgeingAcneHormonal Breakouts
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine in the morning?
What is your current skincare routine in the evening?
How is your current skincare helping your skin?
Are there any specific products/treatments you would like to try?
Are you currently taking any vitamins/ supplements?

YesNoOther
Which of these in-clinic treatments interest you?

SkincareChemical PeelsIPLMicrodermabrasionFacialsDermaplaningPigment reduction - cryotherapySkin TighteningSkin InjectablesMicro-needlingMesotherapyLaserMuscle relaxant injectionsFacial FillersLaser hair removalHair regrowth treatmentFat reduction
Do you use any kind of homecare device on your skin? e.g Facial cleansing tools, home rollers, crystal stone rollers/sculpters, LED masks etc.?

YesNoOther
Which of these price brackets would best describe your financial commitment should you require it to achieve your desired results?

£50 - £100£150 - £350£400 - £600£1000+Please tick here if interested in out payment plan options.
How did you hear about us?

AdvertsRecommendationSearch engineSocial mediaOther
Preferred contact details

PhoneEmail
Take photo of the front of your face here
Or Simply Upload File Here...
Take photo of the left side of your face here
Or Simply Upload File Here...
Take photo of the right side of your face here
Or Simply Upload File Here...
Please select what time suits you best for a scheduled consultation

Weekdays - AnytimeWeekdays - MorningWeekdays - AfternoonWeekdays - EveningsWeekends - AnytimeWeekends - MorningWeekends - Afternoon
Preferred Consultation Day & Time (this is only a request and not confirmation of your booking).
Please feel free to write any further comments that you think may be useful to know in terms of the history of your skin/health, prior to our consultation.
Signature

Clear
Thank you for taking the time to complete this form.

Our skin specialist will be in touch with you within 48hours of receiving this form.

If you haven't heard back please follow up via:

Email - dianna@skintonicormskirk.com

WhatsApp 07591 476867.

www.skintonicormskirk.com

Instagram@skinbydianna
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