Skin Assessment Form
A quick suitability check for accessing our professional skincare range. Please provide your details and preferences.
Name
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Health & Safety
Are you currently pregnant, breastfeeding, or using medications such as Roaccutane (isotretinoin), tretinoin, antibiotics, or steroid creams?
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Yes
No
We do not recommend vitamin A/retinoids or certain active treatments during pregnancy or while using specific medications.
Are you currently using any prescription medication or skincare?
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Yes
No
Do you have any diagnosed skin conditions?
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Acne
Rosacea
Eczema
Psoriasis
Dermatitis
None
Other
Do you have any known allergies or sensitivities?
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Yes
No
Your Skin
Skin type
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Oily
Dry
Combination
Sensitive
Not sure
Main skin concerns
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Acne/breakouts
Pigmentation/uneven tone
Fine lines/ageing
Redness/sensitivity
Dryness/dehydration
Dullness
Congestion/blackheads
Currently using any active ingredients?
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Retinol/Vitamin A
AHAs
BHAs
Vitamin C
None
Not sure
Consent
Some products available through The Skincare Store contain active ingredients that are not suitable during pregnancy, breastfeeding, or when using certain medications. By proceeding, I confirm that:
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I understand that not all products are suitable for all individuals
I will check product suitability for my personal circumstances before use & I confirm I will seek medical advice where appropriate (e.g. pregnancy, medication, skin conditions)
I accept responsibility for the safe use of any products purchased
I understand this is a basic consultation and not a full skin assessment
I agree to follow product instructions and introduce active ingredients gradually.
Please tick the below to receive special offers, discount codes and general skincare advice:
*
I would like to opt in to receive skincare advice via email.
Signature
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Submit
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