Online Skin Consultation
Please take your time completing this form and include as much detail as you can! The more you share with me, the better I can understand your needs, concerns and goals. This will help me provide the most suitable recommendations and personalised treatment options to help you achieve your desired results.
Personal Details
Name
First Name
Last Name
Age
Gender
Female
Male
Prefer not to say
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Medical History
Are you pregnant, IVF or breastfeeding?
Yes
No
Have you taken Roaccutane in the last six months?
Yes
No
Do you have a skin infection/open wound on the treatment area?
Yes
No
Are you allergic to aspirin (acetylsalicylic acid)?
Yes
No
Have you had a cold sore in the last 7 days? If you get cold sores regularly, how frequently does this occur?
Are you currently under the care of a medical professional (e.g. dermatologist)? If yes, please provide more details.
Have you ever been treated for skin cancer? If yes, please provide more details.
Are you taking any prescription medicines (e.g. antibiotics)? If yes, please provide more details.
Are you currently taking any topical prescription medicines (e.g. retinoic acid/topical antibiotic/topical steroids)? If yes, please provide more details.
Do you have any illnesses or health conditions? If yes, please provide more details.
Have you ever been diagnosed with a skin condition? If yes, please provide more details.
Do you have any undiagnosed skin lesions? If yes, please provide more details.
Do you have any allergies? If yes, please provide more details.
Lifestyle
Have you had any aesthetic treatments or surgery within the last 6 months? If yes, please provide more details.
Do you smoke? If yes, how many cigarettes per day?
Do you drink alcohol? If yes, how many units a week?
Do you drink water? If yes, how many glasses a day?
Do you caffeinated drinks? If yes, how many daily?
Do you follow a restricted diet? If yes, please provide more details.
Are you physically active? If yes, please provide more details.
Do you tan regularly or use sunbeds? If yes, please provide more details.
What does a typical day look like for you? Do you work from home/travel to an office? What do your typical meals/snacks look like? Do you get fresh air/sunlight regularly? Are you active throughout the day/when would you typically go to the gym?
Current Skincare
Are you using AHAs/BHAs/non-precription retinol in your current skincare routine?
Have you ever used any skincare products that caused an adverse reaction?
What is your current morning routine? Please include specific products/brands.
What is your current evening routine? Please include specific products/brands.
Do you use any other products occasionally? Please include specific products/brands and how often you would typically use these.
Do you wear sunscreen every day (including winter months)?
Yes
No
Have you had any skin treatments (e.g. chemical peels, microneedling, facials etc)? When did you have these done?
Skin Concerns
What are your main skin concerns?
Acne/Breakout-prone
Blackheads
Redness/Rosacea
Sun damage/Pigmentation
Sensitivity
Wrinkles/fine lines
Hydration
Texture
Dry/flaky skin
Dull skin
When did these problems occur?
Is there a period of time (e.g. in the year/day) when your skin worsens/improves?
What are your main skin goals? What can I help you with?
Please upload clear images of your skin including any areas of concern. Please ensure the images taken are in natural lighting with clean, make-up free skin.
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Consent
I hereby declare that all the information I have given on this form is correct and consent to this data being collected.
Signature
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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