Flawlessceuticals Skin Care Assessment

Full Name* This field is required.

First

Last

E-mail* This field is required.

We will never SPAM or sell email addresses to third parties.

Phone:

ex. 555-555-5555

Date of Birth:

ex. 01/05/1960

What is the best way to contact you?* This field is required.

Phone call

Text

All

How did you find out about Flawlessceuticals?

As well as great skincare, are there any particular conditions below you like to improve?* This field is required.

Acne

Oily Skin

Dry Skin

Bumps

Large Pores

Melasma

Redness

Brown Spots

Sun Damage

Milia

Sagging Skin

Rosacea

Lines & Wrinkles

Healthy Aging

White spots

Scarring

Age Management

Keratosis Pilaris

Hyperpigmentation

Hypopigmentation

How often do you use a skin regime?* This field is required.

1x per day

2x per day

3x per day

I do not use a regime

What is a skincare regime?

When washing my face (select all that apply):* This field is required.

I use hot water

I use warm water

I use cool or cold water

I use face wipes

I do not wash my face

I use soap

I use shower gel

I use a cleansing oil

I use a cleanser and cotton pads

I use a face cloth

Please list any current skin care products you use at home. Include as much detail as possible including brand and product names.

Do you like scented or unscented products?* This field is required.

Scented

Unscented

No preference

Do you wear foundation?* This field is required.

YES

If yes please state your current brand of foundation

Please describe your skin tone and what happens if over exposed to the sun

Pale - Always Burns never tans

Light - Sometimes burns and can tan

Medium - Burns minimally always tans

Dark - Rarely burns, gets minimally darker

Are you allergic to anything?* This field is required.

YES

If yes, please list allergies:

Please list any oral MEDICATIONS , or supplements or herbs you take daily:

Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?* This field is required.

YES

Have you ever had skin cancer?* This field is required.

YES

Currently having treatment

Do you follow a regular exercise program?* This field is required.

YES

What is your current level of stress?

Low

Moderate

High

Do you smoke?* This field is required.

YES

Do you drink alcohol?* This field is required.

YES

Do you follow a special or restricted diet? (Please give details next)* This field is required.

YES

Please give details about special or restricted diet here

Are you pregnant or trying to become pregnant?

YES

Are you on any hormone treatments eg, contraceptive pill, mirena coil, HRT?

YES

List any additional conditions you would like treated:

For best assessment feedback, please upload a photo of your face with no make up and clear lighting, alternatively book in for a face to face consultation at the Clinic.

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Max. file size: 10.6MB

Date* This field is required.

Date

Signature* This field is required.