Your skin is unique…
…so it’s important that your skincare plan is too. Please take some time to work through your consultation form and be as thorough as possible, the more information you can provide, the more I can help.
Street Address Line 2
Your Date of Birth
Your Mobile Number
Your Home Number (optional)
Your Email Address
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Are you currently seeing a Doctor for any medical conditions?
Are you currently taking any medication?
If you answered YES to either of the above questions, please provide details here:
Are you currently taking any supplements or over the counter medication?
If YES, please provide details:
3. Do you suffer from any of the following conditions? (please tick where appropriate)
Recent surgical procedures
Diabetes (Type 1 of 2)
Allergies (including aspirin)
Reactions to skincare / food
Psoriasis / Eczema
Prone to Keloid scarring
Cancer / Chemotherapy
No health conditions
If you ticked any of the above boxes, please provide more details here...
Are you using any topical medications on the face? (Antibiotics, Benzol Peroxide, Roaccutane, other Vitamin A, Steroids)
Do you suffer from stress related symptoms? i.e: insomnia, brain fog, breakouts?
Do any of the following apply? (please tick)
Currently on your menstrual cycle
Are you in any of the 3 stages of Menopause?
Which statement best describes your exercise routine?
I am a gym bunny and live to exercise
I like to look after myself with regular exercise at least twice a week
I try to fit in a weekly class when I can but won't prioritise it
Netflix surfing is about as strenuous as it gets!
Health issues prevent me from keeping up with a regular exercise routine
On average, how many hours a week do you exercise?
What is your favourite type of exercise?
Do you follow any specific diet?
Varied diet including meat, fish and vegetables
Which statement best describes your eating habits?
My body is a temple
I cook every day and enjoy a balanced diet with a full range of fruit and vegetables
I try to eat healthily most of the time but do enjoy a takeaway as a treat
I don't have time to cook unless it goes ping!
How many hours a day do you work?
On average how much unbroken sleep do you have each evening?
How much water do you drink daily?
How much alcohol do you drink weekly?
Do you smoke?
TELL ME ABOUT YOUR SKIN ROUTINE
What product are you currently using?
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:
If YES, please provide product details:
Do you use any at-home devices?
If YES, please tell us more...
How much time do you spend on your skin each week (average)?
Do you use any skin supplement?
If YES, please provide details:
YOUR SKIN GOAL
What Skin Goal would you like help with:
I would like to look better for my age
I have a specific skin concern that I need help with
I want to start looking after my skin
Please tell me more about your skin goal:
Are you struggling with any of the following:
Early signs of ageing
Established / Advanced ageing
Acne / Oily / Probelm skin
Uneven texture / Acne scaring
Pigmentation / Sun damage
Rosacea / Reactive skin
Dull, tired looking skin
Dry, mature skin
How long have you been struggling with this?
Which areas are you most concerned about?
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Please describe how you will feel when you reach your skin goal:
How much time are you willing to invest in your skin to achieve your goal?
Please tick if you have tried had any of the following advanced treatments:
Other - please detail
Please provide details of any other treatments here:
Have you had any injectable procedures?
If YES, what areas have you had treated?
Neck and décollete
What date did you last have a treatment?
Please tell us if you have experienced any skin reactions or sensitivity after treatments or skincare products:
What type of Skin Solution are you looking for?
Home-use Skincare regimen only (pay as you go)
Home-use Skincare and in-salon Treatments (pay as you go)
All inclusive Skin Transformation Programme
YOUR CONSULTATION - THE NEXT STEP
I 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, I know that the best way for us to do this is during an in-depth Skin Consultation. The details you have provided above will help me guide you towards achieving your skin goals.
How would you prefer to be contacted to arrange consultation (choose one)?
I agree for Nikolett Vegh - The Skin Therapist 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 Nikolett Vegh - The Skin Therapist informed of any changes to my health and medication. I consent to Nikolett Vegh - The Skin Therapist contacting me using the contact information provided above.
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