Online Consultation Form
Data Retention Notice – Tranquility Skin collects and stores your personal information for the purpose of providing safe and suitable treatments, maintaining accurate records, and meeting insurance and professional requirements. All data is processed in accordance with UK GDPR and is kept securely.Your information will never be shared with any third party unless required by law.You have the right to access the data we hold about you, request corrections, or ask for your information to be deleted at any time. If you wish to exercise any of these rights, you can contact Tranquility Skin directly
I confirm that I have read and understood the GDPR & Data Protection statement above. I consent to Tranquility Skin collecting and storing my personal and health information for the purposes outlined above.
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Yes
Full Name
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Date Of Birth
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Day
-
Month
Year
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Address
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Street Address
Street Address Line 2
City
Postal / Zip Code
Mobile Number
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Email Address
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Emergency Contact Name
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Emergency Mobile Phone Number
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How did you discover Tranquility Skin?
Social Media
Word of Mouth
Friends/ Family
Leaflet/ Business Card
Other
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How would you best describe your skin?
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Normal/Balanced
Dry
Oily
Combination
Unsure
What are your main skin concerns?
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Acne
Breakouts/ Congestion
Sensitivity
Redness
Dryness
Dehydration
Oiliness
Ageing/ Fine Lines
Dullness
Texture
Other
Please select products you are currently using within your skincare routine (If you have one)
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Cleanser
Exfoliator - Chemical such as AHAs or BHAs etc (Glycolic acid, Salicylic acid etc)
Exfoliator - Physical such as a facial scrub
Toner
Targeted serum for skin concerns
Moisturiser
Retinoid
Eye Cream
SPF
Can you please let me know the brand and names of the products you are currently using? If easier, please feel free to upload a photograph of them instead!
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Choose a file
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Does your skin flush easily?
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Yes
No
Do you tan or burn easily?
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Tan easily
Burn easily
Bit of both
Have you had recent sunburn?
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Yes
No
Have you ever had any anti wrinkle injections, fillers, Chemical peels or laser treatments recently? If so, when?
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Current Medical Conditions
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Heart Condition
High/Low Blood Pressure
Diabetes - Type 1 or Type 2
Epilepsy/seizures
Kidney or liver disease
Autoimmune conditions
Thyroid conditions
Hormonal disorders (PCOS, endometriosis)
Skin conditions (Acne, eczema, psoriasis, rosacea, dermatitis)
Skin cancer (past or present)
Keloid scarring history
Metal implants or pacemaker
Recent surgeries (within 6–12 months)
Claustrophobia (important for masks/LED)
NONE
Other
Medical Treatments or Medications you have had/ are taking
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Chemotherapy/ Radiotherapy (Past or Present
Recent steroid use (Oral or Topical)
Isotretinoin (Known as a prescription acne treatment)
Immunosuppressants
Antibiotics (currently or within last 3 months)
Hormonal contraception
NONE
Other
Do have any allergies to ingredients or products?
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Are you currently pregnant?
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Yes
No
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Occupation
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Stress Level
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Low stress
1
2
3
4
5
6
7
8
9
High stress
10
1 is Low stress, 10 is High stress
How often do you exercise?
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How many hours of sleep do you get per night on average
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Less than 5
5-6
7-8
8+
How much water do you drink daily?
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Less than 1 litre
1-2 litres
2 litres +
Do you smoke or vape?
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Yes
No
How would you describe your diet?
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Mainly whole food
A mix of whole food and processed food
Mainly processed food
How often do you consume alcohol?
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How many cups of tea/coffee do you drink per day?
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I agree to the above statement.
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Yes
Client Name
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Client Signature
Date
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Month
-
Day
Year
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