Alumier Medical Grade Skincare Consultation Form
AC Aesthetics
Name
First Name
Last Name
Age
Email
example@example.com
Which describes you best?
I am new to AlumierMD skin
I am an existing client
What is your current skin regime? Please add brands where possible.
Which best describes your skin?
Aggressive inflamed acne
Mini or hormonal breakouts
Blackheads and oily skin
Dry sensitive skin
Flushed cheeks, Rosacea & broken capillaries
Dull & tired looking skin
Ageing skin
Sun damaged skin
How would you describe your skin type? (Tick all that apply)
Mostly Oily
Mostly Dry
Normal
Combination
Would you describe your skin as sensitive?
Yes
No
Tell me in your own words what you dislike about your skin?
What are your main concerns? (Maximum of two choices)
Breakouts
Texture (bumps/ blackheads)
Scarring
Dry skin
Dull skin
Ageing skin
Uneven skin tone (discolouration)
Have you used roaccutane or accutane in the last 3 months?
Yes, I am still using it
Yes, but I have finished now
No
Do you have any allergies
Are you pregnant or breastfeeding
Yes
No
What is your skin goal?
What is a reasonable budget to achieve this goal?
£100
£150
£200
£250
£300
£350
Please upload a clear photo of your skin in normal daylight, no filters. A photo is necessary for medical purposes and will not be shared outside of AC Aesthetics for review.
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