Name
Phone number
Format: 00 000 000 000.
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 any prescription 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 your ethnic background?
Do you have any medical issues?
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
What is the main reason for your enquiry today?
What are your main skin concerns?
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
Spots
When did you first notice your concern?
Do you notice your skin concern gets worse at any time of the day/month/year?
When I think about my appearance, I feel I look
Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive
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
Which of these in-clinic treatments interest you?
Home Skincare
Chemical Peels
Facials
Dermaplaning
Skin Injectables
Muscle relaxant injections
Facial Fillers
Brow correction
Skin boosters
Are there any specific products you would like to try?
What is your current skincare routine?
How is your current skincare helping your skin?
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
Fresher
Happier
Brighter
More awake
More youthful
Slimmer
More attractive
More illuminous
More confident
Do you have a budget in mind for investing in your skin?
Under £100
£100-£200
£200-£300
£300+
Preferred contact details
Phone:
Email:
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