Name
Address
Street Address
Street Address Line 2
City
County
Post Code
Phone number
Email address
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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 using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
Yes
No
I am using any prescription or topical medications at this time
Yes
No
I have used skincare products that caused an adverse reaction
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?
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 age
would like to change something that has been bothering
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 I 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
More attractive
More luminous
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? Morning and Evening:
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
Microdermabrasion
Facials
Dermaplaning
Pigment reduction - cryotherapy
Skin Tightening
Skin Injectables
Micro-needling
Mesotherapy
Laser
Muscle relaxant injections
Facial Fillers
Facial Threads
Nose augmentation
Brow correction
Eyelid correction
Fat reduction Chin
Capillary Removal
Thread vein removal
Hair replacement
Fat reduction
How did you hear about us?
My doctor
Advertisment
Recommendation
Search engine
Social media
Preferred contact details
Phone
Email
Take Photo: Front
or, Upload Photo: Front
Take Photo: Left
or, Upload Photo: Left
Take Photo: Right
or, Upload Photo: Right
Signature
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