Skin Prescription Consultation Form

Skin Prescription Consultation Form

Skin Prescription Consultation Form

Please give us as much detail as you can to ensure we have an accurate understanding of your skin and health.
Name*

First NameLast Name
HeSheThey/ThemOther
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Skin
Acne/CongestionRosaceaPigmentationEczema/DermatitsAgeingGeneral HealthOther
Tell us about your skin? What do you need help with?
How long have you been experiencing this problem?
How does your skin make you feel?
What have you tried in the past for your skin?
Is there anything that makes your skin better/worse?
What is your current MORNING skincare routine:
Please list what specific products you use and their brands
What is your current EVENING skincare routine:
Please list what specific products you use and their brands
Do you apply anything else to your skin. Including makeup, primers, masks, exfoliants? How often are you using these?
What is your in clinic treatment history:
Laser, Needling, Facials, IPL, Dermabrasion etc

General Skin Health
Do you or your family members have naturally red hair?*
What is your parents ethnicity?*
What is your tanning ability like? Do you tan easily or burn?*
Have you ever used a tanning bed?*
Does your skin itch? Where?*
How long does it take your skin to heal from a breakout, cut etc. *
Do you or your family experience ezcema or dermatitis?*

Female reproductive system
How regular is your cycle?
Do you know the length of your cycle?
What is the duration of flow? eg. starts heavy first two days then lighter
Do you notice any changes around your skin during specific times of your cycle?
Do you experience pain or clotting?
Do you experience PMS symptoms or mood changes before their cycle?
How often do you need to change your pad/tampon/menstrual cup?
Do you experience flooding?

Gut Health
BloatingIndigestionBurpingRefuxHeartburnPain/discomfortNauseaNone of the aboveOther
Do you feel it above or below the belly button?*
Is there a certain time of day where bloating is better or worse?*
How often are you passing a bowel motion?*
Is it easy to pass or is there sometimes straining?*
Do you experience constipation or diarrheoa or fluctuations in both?*
Do you ever notice blood or mucus in your stools or when you wipe?*
Do you have excessive wind?*

Immune Health
How often do you get sick?*
When you get a cold, how long are you sick for?*
When was your last use of Antibiotics?*
UTI'sCold SoresThrushNone of the above
If so, how often?

Images
Please upload at least three images of your skin in natural lighting.
1. Front on, whole face.
2. Left side of face.
3. Right side of face.
4. Any close up images of your skin where you are experiencing the issues.
In order to see how the skin is function within interferecne of lighting, products please ensure:
- Your photos are taken in natural but not direct lighting
- Taken in the same place every time.
- You have cleansed skin, with no products on including moisturiser, SPF and makeup. (First thing in the morning is a good time to take your photos).
- Where possible please use the back facing camera if you are using a phone to take your images.
- Any hair is pulled up away from your face.
Image 1: Front on*

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Image 2: Left side of face*

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Image 3: Right side of face*

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Additional Images: Maximum 6

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Should be Empty: