Client Details
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Skin Profile
What type of skin do you have?
Oily
Dry
Combined
What’s you main skin concern? (Choose all that apply)
Aging
Acne
Blemishes
Redness / Rosacea
Dry
Dullness
Other
If other, please describe here.
What skin care products do you currently use?
Are you currently using any non-prescription retinol in your current skin care routine?
Are you currently using any prescription only skin care? Such as roaccutane.
What have you tried previously to help with your skin concern?
Have you used any skin care products that have caused you to have a reaction? If yes, give details of the reaction and product names.
Aesthetics Treatments
Have you had laser / IPL / radio frequency/ chemical peel in the last two weeks? If yes, give details
Have you had filler injections in the last two weeks? If yes, give details
Have you had Botox in the last 7 days? If yes, give details e.g forehead etc.
Have you had any other aesthetic treatment in the last two weeks? If yes, give details
Lifestyle
Do you smoke?
Yes
No
Do you drink alcohol ?
Yes
No
Do you drink at least 1-2 litres of water a day?
Yes
No
Do you follow a specific diet?
Yes
No
If yes, give details
Are you physically active?
Yes
No
Medical
Are you pregnant, undergoing IVF, or breastfeeding?
Yes
No
Have you used Roaccutane in the last six months?
Yes
No
Do you have any allergies?
Yes
No
If yes, please list your allergies.
Are you currently under the care of a medical professional? Such as a dermatologist, oncologist etc.
Yes
No
If yes, please give details.
Have you ever been treated for skin cancer?
Yes
No
If yes, please give details.
Are you currently taking any prescription medication?
Yes
No
If yes, please list medications here.
Do you have any undiagnosed skin lesions?
Yes
No
If yes, please describe.
Signature
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