Consultation Form
The Skin Instructor
Personal Information:
Full Name
First Name
Last Name
What is your age?
Contact Number
Email Address
example@example.com
Medical History:
Do you have any medication allergies?
Yes
No
Not Sure
Any current medical conditions?
Please Select
Yes
No
If so, please list them below:
Any chronic skin conditions (e.g., eczema, psoriasis)?
Please Select
Yes
No
If so, please list below:
Allergies (including allergies to skincare ingredients)?
Please Select
Yes
No
If so, please list below:
Current medications (prescription and over-the-counter)?
Please Select
Yes
No
If so, please list below:
History of surgeries or medical procedures?
Please Select
Yes
No
If so, please list below:
Cosmetic History
Have you undergone any cosmetic treatments or procedures in the past?
Please Select
Yes
No
If so, please list below:
Have you experienced any adverse reactions to previous treatments?
Please Select
Yes
No
If so, please list below:
Have you had experience with injectables (Botox, dermal fillers)?
Please Select
Yes
No
If so, please list below:
Have you undergone chemical peels, microdermabrasion, or laser treatments?
Please Select
Yes
No
If so, please list below:
Skincare Routine:
Can you describe your current skincare routine and the brand of the products (cleansers, moisturizers, serums)?
Do you have any specific skincare concerns (e.g., dryness, oiliness, acne)?
Please Select
Yes
No
If so, please list below:
Have there been any recent changes in your skincare products or routine?
Please Select
Yes
No
If so, please list below:
Lifestyle Factors:
What is your occupation and daily routine?
How would you describe your sun exposure habits, and do you regularly use sunscreen?
Do you smoke or consume alcohol?
Please Select
Yes
No
If so, please how often below:
Skin Concerns:
What are your primary skin concerns (e.g., acne, pigmentation, fine lines)?
Are there specific areas of concern on your face or body?
Do you have any specific goals or expectations for the consultation?
Photography:
Do you provide consent for the taking of photographs for documentation and analysis?
Please Select
Yes
No
Preferred Communication:
What is your preferred method of communication (phone, email, video call)?
Please Select
Phone
E-mail
Videl Call
Other
Additional Information:
Is there any additional information or questions you would like to share?
Submit
Should be Empty: