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.
Your Name
First Name
Last Name
Your Address
Street Address
Street Address Line 2
Town/City
County
Post Code
Your Date of Birth
/
Day
/
Month
Year
Date
Your Mobile Number
Your Home Number (optional)
-
Area Code
Phone Number
Your Email Address
*
example@example.com
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YOUR HEALTH
Are you currently seeing a Doctor for any medical conditions?
*
YES
NO
Are you currently taking any medication?
*
YES
NO
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?
YES
NO
If YES, please provide details:
3. Do you suffer from any of the following conditions? (please tick where appropriate)
Heart problems
Asthma
Rosacea
Polycystic ovaries
Recent surgical procedures
Diabetes (Type 1 of 2)
Allergies (including aspirin)
Reactions to skincare / food
Psoriasis / Eczema
Prone to Keloid scarring
Epilepsy
Herpes virus
Cancer / Chemotherapy
Claustrophobia
No health conditions
Other
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)
*
YES
NO
Do you suffer from stress related symptoms? i.e: insomnia, brain fog, breakouts?
Do any of the following apply? (please tick)
Currently pregnant
Currently nursing
Currently on your menstrual cycle
Are you in any of the 3 stages of Menopause?
Peri-menopause
Menopause
Post-menopause
Not applicable
YOUR LIFESTYLE
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?
Vegetarian
Vegan
Pescatarian
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?
YES
NO
TELL ME 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 spend on your skin each week (average)?
Do you use any skin supplement?
YES
NO
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
Uneven complexion
Dry, mature skin
How long have you been struggling with this?
Which areas are you most concerned about?
Forehead
Eyes
Cheeks
Jawline
Neck
Decollete
Body
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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?
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:
Have you had any injectable procedures?
YES
NO
If YES, what areas have you had treated?
Cheeks
Eye area
Neck and décollete
Forehead
What date did you last have a treatment?
/
Month
/
Day
Year
Date
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)?
Telephone
Email
Text
WhatsApp
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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