CERA Skin Clinic Online Form

BEFORE YOU START

There are few things we need you to know before submitting the form:

We will keep records of the information provided to legally provide you with a prescription. It is very important you fill out the questionnaire fully and honestly.
We use your answers to diagnose your skin concerns, prescribe home skincare and support you. Your information is stored securely on an encrypted server and never shared without your consent.
Before you can submit this form, we would ask you to upload 3 make-up-free pictures – front and both sides. Please use a plain background (e.g. wall) with daylight and no camera filters on. Please note – we can`t perform an online consultation without pictures of your skin. We will use these pictures to diagnose your skin concerns.
Occasionally, we might ask you to resubmit unclear pictures or may ask you to clarify answers before starting to work on your consultation.
This service is only for Australia-based clients. By signing this form, you confirm that you live in Australia.
To provide you with the best possible care and recommendations, our online skin consultation services are available to individuals aged 18 and above.
This is general advice only and does not constitute to a medical examination by a doctor.
Once we receive your completed questionnaire, we will email you our observations and skincare recommendations within 5 working days.

Please remember to check your spam folder in case the email ends up there.

LET`S START BY GETTING TO KNOW YOU

Full name*

What is your age?*

This helps to determine about your biological ageing process and hormonal influence.

Email address*

We will send your prescription here.

In which state do you live?*

This service is provided for Australia based clients. We do not consult clients internationally as we are not able to ship skincare worldwide.

What do you do for work?*

This will help us to understand lifestyle factors that might impact your skin (sun exposure, stress levels, work shifts you do, etc.).

WE NEED TO KNOW A FEW THINGS ABOUT YOUR MEDICAL HISTORY

This will help us to understand your inner health that is connected to the skin as well as possible side effects.

Do you have any medical conditions? If yes, please specify.*

Are you currently on any medication? If yes, please specify.

Do you take any Vitamins? If yes, please specify.

Do you use hormonal birth control such as Pill/Mirena/IUD/implant?

We need to know this as this can affect pigmentation and oil production.

Are you pregnant or breastfeeding? *

Some of our products cannot be used during pregnancy, however we have pregnancy/safe alternatives.

Have you ever been prescribed Roaccutane/Doxycycline?

If yes, please specify for how long and when was the last time you took it?

Do you smoke?

YesNo

WEE NEED TO KNOW A FEW THINGS ABOUT YOUR LIFESTYLE AND WELLBEING

Do you exercise regularly?

This helps to understand the blood flow levels in your body.

Please rate your current stress level on a daily basis from 1 being very low and 10 being very high. *

This helps us to understand cortisol level in your body that is connected to your skin.

Do you fall asleep easily?

Yes, within 10min.No, it takes time.Other

How many coffees do you drink a day?

This helps us to understand cortisol level in your body that is connected to your skin.

Do you eat sweets? (This will help us to understand the level of inflammation in your skin.)

RareFew times a weekEvery day

Do you eat dairy products every day? (This will help us to understand the level of inflammation in your skin.)

YesFew times a weekI don`t eat it

How much water do you drink a day?

2L (8 glasses)1L (4 glasses)Less then 1L

How regular is your bowel movement?

Every day4-5 a week2-3 a week1-2 a week

This will help us understand the health of your digestive system.

WE NEED TO KNOW A FEW THINGS ABOUT YOUR SKINCARE AND TREATMENTS

What is your current skincare routine in the morning and evening? Please write steps and include the product brand name you are currently using. *

Have you ever used medical grade/pharamedical skincare before? If yes, please specify what brand?*

It can only be prescribed after skin assessment, you can`t get it off the counter.

Do you use sunscreen when outside?*

Yes, alwayYes, most of the timeRarelyNever

Have you ever had a reaction to a skincare product? If yes, please specify.*

Swelling, burning, stinging, redness, peeling

Have you ever had a professional in-clinic skin treatment?

If yes, please specify what kind of treatment and when was the last time you had it?

Do you regularly have or plan to have any of the following treatments?*

WE NEED TO KNOW ABOUT YOUR SKIN CONCERNS

What is your main skin concern?*

If you could only change one thing in your skin, what would it be?*

What is the main reason you filled out this form today?*

My current skin care doesn`t work for meI am not sure how to look after my skin and if I am using the right productsI want to replace my current skincareOther

Is there any other concerns you have or information you would like to share with us?

YOU ALMOST DONE! WE JUST NEED SOME PICTURES OF YOUR SKIN TO SAFELY DIAGNOSE AND PRESCRIBE YOUR SKINCARE AS WELL AS FOLLOW YOUR SKIN PROGRESS.

Please upload 3 pictures of your skin - front and both sides that are make-up free. Please use a plain background with daylight and hair tied up.

See an example below.

If the pictures submitted are too dark and not clear, we can`t proceed with skin assessment.

How would you like your consultation to be delivered?*

Email (please make sure to check Spam folder if expecting results)Scheduled phone call

If you have chosen scheduled phone call, please leave your phone number here and best day and time to be contacted?

How did you hear about us?*

GoogleSocial mediaFriendOther

If we have been recommended by a friend, please tell us their full name.

So we can send them a gift card.

Please upload your skin pictures here*

I consent that information provided is true and correct to the best of my knowledge.*

Thank you for filling out the questionnaire! We will get back with our observations and recommendations within 5 business days.

Please check your spam folder in case the email ends up there.