Skin Care Consultation Form
Please fill out your details to receive personalised skin care advice.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please include a valid phone number
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
0
01
011
0111
01111
Year
Fitzpatrick Scale
*
Type I
1
2
3
4
5
Type VI
6
1 is Type I, 6 is Type VI
Do you have any current health / hormonal conditions?
Fitzpatrick scale definition: Type I always burns and never tans; Type II usually burns and tans minimally; Type III sometimes mild burns and gradually tans; Type IV rarely burns and tans easily; Type V very rarely burns and tans very easily; Type VI never burns and tans very easily.
What is your skin type?
*
Normal
Dry
Oily
Combination
Sensitive
Other
What are your main skin concerns?
*
Acne or breakouts
Redness or irritation
Dryness or flakiness
Oiliness
Fine lines or wrinkles
Dark spots or uneven tone
Sensitivity
Dark spots/ uneven tone
Dullness
Acne scarring
Melesma
Loss of firmness
Dark eye circles
Hyperpigmentation
Dehydration
Sun damage
Rough skin
Other scars
Large pores
Other
What are your aesthetic/skincare goals?
Do you have any allergies or sensitivities?
Do you currently take any supplements? (eg. b12/biotin)
What skincare products and are you currently using/having ?
What's your current AM & PM routine
How much do you currently spend on skincare products?
Any additional information or questions?
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Right Side
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