UDB Skin Clinic - Personalised Skin Consultation Form

UDB Skin Clinic - Personalised Skin Consultation Form

Start your journey to flawless skin! Fill out this form to help us understand your skin's needs and tailor our treatments just for you.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Preferred method of contact

EmailPhoneWhatsApp
How do you identify?

MaleFemalePrefer not to sayOther
How did you hear about me?

Website / Online SearchYelpFacebookReferralOther
If Referral, please list name
If Other, please let me know
How would you like to receive your skin consultation?

In-PersonVirtual
If you choose to have a virtual consultation, which format would you prefer?

WhatsAppZoomFacetime
If you chose an in-person consultation, would you like to have your facial services added onto it, on that day?

YesNo
Please suggest your ideal dates/times for us to call you:
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturiser(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
Do you travel frequently?

YesNo
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

YesNo
Do you have any skin conditions such as eczema or rosacea? If so, please specify

YesNoOther
Your Health
Please specify
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Do you experience pain on your face or body?

YesNo
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo
If yes, please specify what and date last used
Are you a smoker?

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

YesNo
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level

LowMediumHigh
Please let me know if you would like to learn about natural ways to lower stress levels
FEMALE CLIENTS
Are you taking birth control?

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues?

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system?

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
Do you agree to share this information with UDB Skin Clinic to create a personalised skincare plan?

YesNo
Would you like to receive updates on promotions and skincare tips from UDB Skin Clinic?

YesNo
Signature*

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Date

MonthDayYear
Date
Thank you for completing our consultation form!

We have received your information and are excited to begin crafting a personalised skincare plan tailored just for you. A member of our team will be in touch soon to discuss your next steps. In the meantime, if you have any questions, feel free to contact us. We look forward to helping you achieve beautiful, healthy skin!
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UDB Skin Clinic - Personalised Skin Consultation Form

Your Skin

Your Health