Kate Cottle Wellbeing & Skincare Consultation Form 2022

Kate Cottle Wellbeing & Skincare, Rawdon

New Enquiry / Client Pre-Consultation Form
Thank you for your enquiry and for taking the time to complete the following form. It will help me to understand what your requirements are and how I can best help you achieve the results you'd like.

Once I've received your form, we can arrange a video consultation to discuss things further.

If you experience any difficulties submitting the form, please do let me know - my number is 0113 436 3934 or 07901 750 598

Thank you

Kate Cottle
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone number*

Country CodePhone Number
Email address*
example@example.com
Would you like to be added to my mailing list to hear about news, updates and promotions, from time to time?
AlumierMD Professional Skincare Product RecommendationAdvanced FacialsChemical PeelsMicro-NeedlingLED Light Treatments, PhototherapyMassage & RelaxationHD Brow TreatmentFacial WorkoutHolistic Facials
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you answered YES to any of the above questions, please give further details here:
What is the ethnic background of your parents?
Do you have any medical conditions?*
YesNo
YesNo
If yes, please give further details here:
YesNo
If yes, please give further details here:
I would like to learn how to look after my skin properlyI would like to improve my skin's overall appearanceI would like to find a solution for my skin's redness or rosaceaI would like to address my skin's sensitivityI would like to get help with my skin's breakouts and congestionI have an upcoming special event which I would like to look my best forI would like to reduce my skin's hyperpigmentation, sunspots and uneven toneI would like to reduce the appearance of scarringI feel I have suddenly aged and am not happy about itI feel I look older than I would likeI would like my skin to be firmerI would like my facial features & contours to be more defined and liftedI am quite happy with my skin, no major issues, but would like to maintain it wellI would like a clearer, radiant complexionOther
Most daysWeeklyMonthlyOnly very recentlyFor years
DullDroopyFreshHappySadBrightUnattractiveFed up and tired, hardly recognise myselfFrustrated, nothing seems to workI feel quite proud and rarely wear makeupA bit 'muddy', skin tone is uneven, I feel like I need to wear more makeupJust not as confident as I used to beToo many wrinkles for my likingI quite like my skin but my eyes look so tired
On a scale of 1 - 10, 1 being very unhappy and 10 being extremely happy, how satisfied are you with your skin's health & appearance?
FresherHappierBrighterMore awakeMy skin looks more youthful & luminousMy skin is clearer, fewer breakoutsMy skin is firmer and has more density - feels plumperI feel more confident to wear less or no make-upLines and wrinkles look shallower & less visibleMy skin is much smootherMy skin is more evenly toned, brown marks are reducedOther
Lines & wrinklesLoss of volume, skin looks thinner than it used toLoss of elasticity, skin seems to be saggingCriss-cross lines (glycation)Dry, flakey, make-up looks patchyOilinessOpen poresBlackheadsWhiteheadsBumps and pimples under the skinBreakouts, spots, active acneAcne scarring, pittingSallow, yellow, dull, 'waxy' complexionAge spots, sun damage (hyperpigmentation)Uneven skintoneFrecklesBroken capillariesFlushing, redness, RosaceaSensitivitySkin feels hot / tenderOther
What is your priority concern?*
When did you first notice this?
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine, which products are you currently using, if any?
Do you feel your current skincare is helping your skin?
Are there any specific products or ingredients you would like to try, if suitable?
Friend's recommendationGoogleFacebookInstagramStockists websiteOther
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Take a photo of your LEFT side
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Take a photo of your RIGHT side
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Please enter your date of birth*

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Please sign & date here to confirm that you are happy for me to receive the above data & images to help me provide you with an appropriate consultation and safe treatment. They will remain confidential at all times unless you expressly give permission to share, at a later date. Thank you*

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Kate Cottle Wellbeing & Skincare, Rawdon