Consultation Form
Please complete this form to help us provide the best consultation and care for your needs.
Personal Information
Tell us about yourself.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Country
*
Please Select
UK
USA
Nigeria
Other
Medical & Health Information
Please let us know about your health for your safety.
Please tick any that apply:
*
Pregnancy / Breastfeeding
Diabetes
Epilepsy
High / Low Blood Pressure
Autoimmune condition
Skin condition (Eczema, Psoriasis, Dermatitis)
Allergies (please specify)
Recent surgery (last 6 months)
Currently under GP or specialist care
None
If you selected any of the above, please give details:
Skin Assessment
Help us understand your skin.
How would you describe your skin?
Dry
Oily
Combination
Sensitive
Acne-prone
Hyperpigmentation
Rosacea
Main skin concerns:
Dark spots
Uneven tone
Stretch marks
Fine lines
Dullness
Body breakouts
Scarring
Current skincare products used:
Have you used any of the following active ingredients?
Retinol
AHA/BHA
Hydroquinone
Chemical peels
None
Lifestyle Questions
Tell us about your daily habits.
Water intake per day (in litres):
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
On a scale of 1 to 10, how would you rate your current stress level?
1 (Low)
1
2
3
4
5
6
7
8
9
10 (High)
10
1 is 1 (Low), 10 is 10 (High)
Treatment / Product Consultation
Let us know what services you are interested in.
Service(s) you are interested in:
*
Facial
Body polish
Acne treatment
Hyperpigmentation treatment
Stretch mark treatment
Baby skincare consultation
Product recommendation only
What results are you hoping to achieve?
Consent & Liability
Please read and acknowledge the following statements.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Savvvy Cosmetics complies with UK Cosmetic Regulation (EC) No 1223/2009 and follows professional treatment safety standards.
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