CRYSALLIS SKIN CLINIC CONSULTATION
Please provide as much information as possible to allow us to provide a targeted skin solution designed to help you reach your skin goals.
Your Name
First Name
Last Name
Your Mobile Number
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Your Email Address
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TELL US ABOUT YOUR SKIN ROUTINE
What product are you currently using?
Day
Night
Weekly
How long have you been using this regime?
Are you using any active products that contain Vitamin A (Retinol), Glycolic or Salicylic Acids? If YES, please provide product details:
YES
NO
If YES, please provide product details:
Do you use any at-home devices?
YES
NO
If YES, please tell us more...
How much time do you currently spend on your skin each week (average)?
Do you use any skin supplement?
YES
NO
If YES, please provide details:
Are you struggling with any of the following:
Early signs of ageing
Established / Advanced ageing
Oily / Probelm skin
Uneven texture
Pigmentation / Sun damage
Rosacea
Dull, tired looking skin
Uneven complexion
Dry, mature skin
Sensitive skin
Enlarged pores
Acne - mild
Acne - moderate
Acne - severe
Acne scarring
How long have you been experiencing these problems?
Which areas are you most concerned about?
Forehead
Eyes
Cheeks
Jawline
Neck
Decollete
Body
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Your Skin Goal
What Skin Goal would you like help with?
I have a specific concern that I need help with
I want to start looking after my skin
I want to look better for my age
Tell me more about your skin goal
Please describe how you will feel when you reach your skin goal:
TREATMENT HISTORY
Please tick if you have tried had any of the following advanced treatments:
Skin needling
Light therapy
Radiofrequency
Facial laser
Facial IPL
Skin peels
Other - please detail
Please provide details of any other treatments here:
Please tell us if you have experienced any skin reactions or sensitivity after treatments or skincare products:
To help me guide you to the best skin programme, please let me know what level of skincare solution are you looking for
Home-use Skincare regimen (pay as you go)
Combination of home-use Skincare regimen and in-clinic treatments (pay as you go)
12 week Intensive Clear Skin Solution (from £760)
6 - 12 month Clear Skin Subscription - my ultimate ALL INCLUSIVE Home-use Skincare and in-salon Treatment Subscription (from £1999)
YOUR CONSULTATION - THE NEXT STEP
At Crysallis Skin Clinic we appreciate that no two clients are the same, and neither is their skin. Surveying the condition of your skin's health is an essential step to devising a treatment plan that targets your specific skin concerns. From experience, we know that the best way for us to do this is during an in-depth Skin Analysis Facial Treatment. The details you have provided above will help us match you with your ideal Skin Therapist who will contact you directly via your preferred contact method to book your appointment. To take the NEXT STEP towards your skin goals, please complete the booking payment below...
How would you prefer to be contacted to arrange consultation (choose one)?
Telephone
Email
Text
WhatsApp
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I agree for Crysallis Skin Clinic to retain the information included in this document. I confirm that the information I have provided is correct to my knowledge and that I will keep Crysallis Skin Clinic informed of any changes to my health and medication. I consent to Crysallis Skin Clinic contacting me using the contact information provided above.
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