New Client Skin Consultation Form
Welcome to Perth Natural Beauty. This in-depth consultation is designed to help us understand your skin, lifestyle and goals, so we can create a personalised treatment and home care plan just for you.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 0000-000-000.
Date of Birth
*
-
Day
-
Month
Year
Occupation
*
What are your main concerns?
*
Acne / Breakouts
Pigmentation / Uneven skintone
Ageing / Fine lines
Sensitivity / Redness
Rosacea
Dehydration
Congestion / Blackheads
Eczema / Dermatitis
Dull complexion
What are your goals?
*
Clear skin
Even skin tone
Anti-aging / Firming
Strengthen skin barrier
Long-term skin health
How would you describe your skin?
*
Dry
Oily
Combination
Sensitive
Unsure
Do you have any of the following, past or present?
*
Acne
High blood pressure
Cancer
Cataracts
Claustrophobic
Diabetes
Eczema/Dermatitis
Epilepsy
Hay Fever
Heart disease/condition
Lupus
Metal implants
Thyroid
Varicose veins
None
How does your skin feel most days?
*
Do you experience any of the following?
*
Tightness
Itching
Breakouts
Flushing
None
Please list known allergies, medications or any medical conditions below
*
Do you have a current skincare routine?
*
Yes
No
If yes, what skincare products are you currently using? Please list brands and product names below
*
What are your stress levels?
*
Please Select
Low
Moderate
High
What is your average water intake a day?
*
Please Select
Low (Under 1L)
Moderate (1-2L)
High (2-3L)
How many hours do you sleep on average?
*
Please Select
2-6 hours
6-8 hours
8-10 hours
Have you ever had (tick all that apply)
*
Facial
Peels
Skin Needling
Laser
Microdermabrasion
Botox
Topical antibiotics
Roaccutane
Retinol
Cosmetic surgery
Do you smoke or vape?
*
Please Select
Yes
No
Sometimes
Do you drink alcohol?
*
Please Select
Regularly
Sometimes
On special occasions
Never
FOR WOMEN
*
I am pregnant or trying to get pregnant
I currently take hormone replacements
I experience hormonal imbalances
I am currently on contraceptives
Not Applicable
Please provide clear photos of your face in natural light, including: front view, left side, and right side
*
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Skin Images
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I have read and agree to the Skin Consultation Terms & Conditions provided by Perth Natural Beauty. I understand that this consultation is for cosmetic skincare advice only and does not constitute medical advice. I confirm that all information I have provided is true and accurate to the best of my knowledge. I acknowledge that results may vary and are not guaranteed, and I accept the risk of potential skin reactions. I agree to patch test any new products, and I understand that Perth Natural Beauty is not liable for adverse reactions caused by undisclosed conditions or misuse of products. I consent to providing photos for assessment if required. I understand that consultation fees are non-refundable once the consultation is completed, and I agree to the cancellation policy requiring 24 hours’ notice. I also consent to receiving personalised skincare recommendations
Signature:
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