Acne Programme Enquiry Form

WAVES SKIN THERAPY
SKIN DEEP ENQUIRY FORM

Enquiry Form
Name

First NameLast Name
Email
example@example.com
Date of Birth (please note this programme is only available to clients 18 or over)

DayMonthYear
Please provide us with some information about your skin concerns.
Please feel free to share any photos of your skin.

Browse Files

Cancelof
Female Health

This section does not need to me completed if it is not applicable to your current gender or assigned gender at birth
Are you currently using any of the below methods of contraception

Oral Contraceptive PillCopper CoilMirena CoilInjectionIUDOther
If you have stopped using one of the above contraceptives within the last 3 months, has your natural cycle started?
Have you been diagnosed with any of the below conditions

PCOSEndometriosisFibroidsOvarian Cysts
If you selected any of the above conditions, how were you diagnosed e.g. bloodwork, ultrasound?
Are you currently pregnant, breastfeeding or trying to conceive?

YesNo
Are you currently being treated for any menopause related symptoms? Please provide details including if you are undergoing hormone replacement therapy
General Health
Do you have any diagnosed medical conditions? (not covered above)

YesNo
If you have answered 'yes', please provide details
Are you currently taking any medications, supplements or herbal remedies? If so, please provide details of name, brand and dosage
Have you used any medications, topical or oral, to treat acne in the past? If so, please provide as much information as possible on the type of medication, when you used it, and for how long.
Do you have a neurological condition such as ADHD or Autism?
Nutrition & Fitness
What is your dietary preference?

VegetarianVeganPescatarianNo PreferenceOther
Are you currently under the care of a Personal Trainer, Nutritionist, Wellness Coach etc?
Are you currently following a specific nutrition or diet plan?
To join this programme, we will need to analyse your blood work and assess your symptoms to uncover the underlying causes of your acne.

Success in this programme hinges on your commitment and accountability, so we only accept clients who are truly dedicated to making lasting changes for healthier skin and a happier life.

If you are ready to take this next step, please press submit! We will be back in touch soon to either set up a free Discovery Call or get you started on the programme.
Are you ready to start the programme or would you prefer a Discovery Call to find out more?

I'm ready to start my journey to clear skinI'd like to chat to find out more and ask some questions
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WAVES SKIN THERAPY

SKIN DEEP ENQUIRY FORM

Female Health

General Health

Nutrition & Fitness