Enquiry
Name
First Name
Last Name
Email
example@example.com
Instagram Handle (if applicable)
D.O.B
-
Month
-
Day
Year
Date
Occupation
Why do you want a place on The Internal Healing Method?
Please give a detailed description of your current skin concerns? Include previous history and dates where possible.
Are you currently using any method of contraception?
Oral Contraceptive Pill
Mirena Coil
Copper Coil
Injection
Natural Cycles/Fertility Awareness Method
Condoms
None
Have you ever been placed on contraception for any other reason than to prevent a pregnancy? Eg) Heavy or painful periods, acne.
Yes
No
Do you currently have a skincare routine?
Yes
No
If yes, what are you currently using in your regular skin routine? AM & PM. Please be as detailed as possible, including brand names.
Do you or have you ever had any diagnosed health conditions? Please be as detailed as possible.
Have you ever been diagnosed with PCOS, Endometriosis, Ovarian Cysts or Fibroids?
Yes
No
If you have been diagnosed with PCOS, how was this found?
Blood Work
Ultrasound
Both
Are you currently taking any medication? Please be as specific as possible, including names and doses.
Have you ever been prescribed or used any medication for acne? Oral or topical. Please be as specific as possible, including dates and doses.
Are you currently taking any supplements? Please be as specific as possible, including brand names and doses.
Could you be pregnant or are you trying to become pregnant?
Do you smoke or vape?
Yes, full time.
Yes, socially - weekly.
Yes socially - monthly.
Past smoker/vaper.
Never smoked or vaped.
Do you use or take recreational drugs?
Yes
No
Do you have any menopausal issues? If so, are you under-going hormone replacement therapy?
Are you following any diet plans? Please be specific with this.
Do you have any dietary preferences?
Vegan
Vegetarian
Pescatarian
Omnivorous (you eat meat, fish, plants)
Are you currently working with any other health practitioners? Eg) personal trainer, nutritionist, fitness coach.
Do you have a specific goal or event that you would like to achieve your skin goals by?
Please upload a photo of your skin.
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The Internal Healing Method requires blood work to be taken allowing Lauren to analyse the results along with your presenting symptoms. A targeted protocol will be devised to address the root cause of your acne permanently. Because of this, it is essential that all participants are committed to the programme and understand that accountability is essential in achieving the results. Therefore, we will only accept people who are dedicated and ready to change their lives and their skin, for good. Are you prepared to make this commitment?
Yes, I will be 100% committed to the programme and the process.
No - I don’t think is for me. (If this is the case, please don’t submit the form)
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