SKIN CONSULTATION FORM
PERSONAL DETAILS
Full Name
*
First Name
Last Name
DOB
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Contact Number
*
Email Address
*
Preferred method of contact:
Phone
Email
No preference
MEDICAL INFORMATION
Do you have any medical issues? If YES, please provide details:
Do you take any medication? If YES, please provide details:
Have you taken Roaccutane (Isotretinoin) in the last 12 months?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Do you have an allergy to aspirin? (acetylsalicylic acid)
*
Yes
No
Do you have any other allergies?
*
Yes
No
Do you currently have any infection/open wounds on your skin?
*
Yes
No
Have you been exposed to the sun or used a tanning bed in the last 3 weeks?
*
Yes
No
Do you currently use sunless tanning products?
*
Yes
No
Do you smoke?
*
Yes
No
Are you using any prescription or non-prescription retinoids? (e.g. retinol, Retin-A®, Tazorac®)
*
Yes
No
Are you currently using any prescription topical medications?
*
Yes
No
Have you ever used skincare products that caused an adverse reaction?
*
Yes
No
If you answered YES to any of the above, please provide details:
SKIN INFORMATION
What is the main reason for your enquiry today?
What are your main skin concerns?
What is the ethnic background of your parents?
How would you describe your skin type?
Normal
Dry
Oily
Combination
Sensitive
Dehydrated
Other
When did you first notice your skin concern?
Do you notice your skin concern gets worse at any time of the day/month/year?
Are there any triggers that make your skin worse?
Stress
Medication
Diet
Mask wearing
Hormonal
Sunlight
Change in weather
Other
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
Other
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 treatments interest you?
Skincare
Chemical peels
Facials
Skin injectables (e.g. Profhilo)
Anti-wrinkle injections
Dermal fillers
Have you had any aesthetics treatments before? If YES, please provide details:
How did you hear about me?
Search engine
Google Ads
Facebook
Instagram
Word of mouth
Recommendation
Other
PHOTOGRAPHS
Upload photos to complete your skin assessment. They will not be shared without your consent.
File Upload (Front View)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload (Left View)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload (Right View)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
SIGNATURE
I confirm I have answered this to the best of my ability:
*
Submit
Should be Empty: