Online Skin Consultation
Please complete this short questionnaire so that we can learn more about your skin. It will only take 5-10 minutes. You will then be prompted to book in a complimentary telephone call with one of our skin specialists to go through your form and recommend products.
Personal Details
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Phone Number
*
Please enter a valid phone number.
Format: (00000000000.
Email
*
example@example.com
Medical Questionnaire
Are you allergic to anything?
*
Yes
No
If yes, please provide more information below:
Do you have an allergy to aspirin? (acetylsalicylic acid)
*
Yes
No
Are you currently pregnant or breastfeeding?
*
Yes
No
Are you currently taking any oral medication for your skin?
*
Yes
No
If yes, please provide more information below:
Are you currently using any topical medication on your skin?
*
Yes
No
If yes, please provide more information below:
Have you taken roaccutane for your skin within the past 6 months?
*
Yes
No
Have you been formally diagnosed with any chronic skin condition or disease?
*
Yes
No
If yes, please provide more information below:
Have you ever experienced any adverse reaction to skincare products in the past?
*
Yes
No
If yes, please provide more information below:
Skin Consultation
Please list the products that you are currently using on your skin:
*
What is your budget for your skincare?
*
£50.00-£100.00
£100.00-£150.00
£150.00-£200.00
£200.00-£300.00
£300.00+
What are your main skin concerns?
*
Which of these apply to your skin?
Lines (superficial)
Wrinkles
Decreased volume
Loss of elasticity (saggy skin)
Glycation (criss-cross wrinkles)
Dryness
Blackheads
Whiteheads
Cysts (boils)
Acne Scarring
Sallow (yellow/dull) complexion
Oiliness
Open pores
Hyperpigmentation (brown spots)
Hypopigmentation (white spots)
Uneven skintone
Freckles
Broken capillaries
Inflammation
Redness
Sensitivity
How would you describe your skin?
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Oily
Dry
Sensitive
Combination
Which of these best describes your skin?
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I wake up with oily skin
My skin gets oilier throughout the day
I am not very oily
Other
If your skin gets oilier throughout the day, which of these would best describe your skin?
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I am not oily
It's enough oil to blot and wipe away
I just notice that my make-up gets a little bit shiny
Other
Do you have large open pores around your nose and cheeks?
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Yes
No
Other
When you get out of the shower, bath or after washing your face, does your skin feel dry and tight? (Like you need to moisturise?)
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Yes
No
Other
Do you ever get redness after washing your face?
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Yes
No
Other
Would you describe your skin as sensitive?
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Yes
No
Other
How often do you break out?
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Daily
Weekly
Monthly
Rarely
Other
Are your breakouts localised to one area?
How do you usually remove your makeup?
Are there any specific products that you are interested in trying?
Which of these in-clinic treatments interest you?
Hydrafacial
Chemical Peels
Facials
Skin Injectables
Micro-needling
Muscle relaxant injections
Lip Filler
Facial Fillers
How would you describe your diet?
*
How much water do you drink each day?
*
Do you smoke?
*
Yes
No
Socially
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Rarely
Other
Do you currently take any daily supplements?
*
Do you use any form of hormonal contraception?
Pictures
Take Photo - Front
Take Photo - Left
Take Photo - Right
Signature
Thank you
Your online skin consultation is complete!
You will now be redirected to book in a complimentary phone call with one of our skin specialists to go through your consultation form and recommend products to help your skin, so please ensure all details are correct!
If you wish to get in touch, please send us a DM on instagram or email info@secretenhancements.co.uk
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