Skin by Catherine Maria - Online Skin Consultation Form

What is your full name?

Your date of birth

Email address

example@example.com

Your full address and postcode

Contact Number

Are you currently using or have used Accutane (isotretinoin) in the last six months?

Are you pregnant, trying to or currently breastfeeding?

Do you have any allergies? If yes, please give details

Are you allergic to aspirin (acetylsalicylic acid)?

Do you have a skin infection/open wound in the treatment area?

Have you been exposed to the sun or used a tanning bed in the last 3 weeks?

Are you currently using sunless tanning products?

Are you using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)?

Are you using any prescription topical medications at this time?

I have used skincare products that caused an adverse reaction

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?

Have you under gone any facial cosmetic procedures, e.g. botox and dermal fillers?

What is the main reason for your enquiry today?

Which skin type do you have?

Is your skin sensitive? If yes, please list what you are sensitive to

Which of these statements is most applicable to you?

Have you had an aesthetic consultation or treatment before?

How often do you think about having an aesthetic treatment?

When I think about my appearance, I feel I look - please tick three

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

What are your main skin concerns?

When did you first notice your concern?

Which of these apply to your skin?

Do you notice your skin concern gets worse at any time of the day/month/year?

What is your current morning skincare routine? Please mention brands & if you wear any SPF

How often do you exfoliate? Which products do you use to exoliate?

What is your current evening skincare routine? Please mention brands

How long have you been using these products?

How is your current skincare helping your skin and have you noticed any improvements?

Would you like to invest in a medical grade skincare routine to help you achieve your skin goals?

What is a realistic skincare budget for you? This will enable me to develop a bespoke plan for you.

Which of these in-clinic treatments interest you?

How did you hear about us?

I give consent for my photos to be used on social media *Skin by Catherine Maria will seek permission, before using any photos for social media*

Preferred contact details