Cheshire Lasers ZO Skin Health & pHformula Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Mobile phone
*
Occupation
*
We use the following methods of contact for appointments and purchases. Please tick if you do not want us to use any of the following.
Phone
Email
WhatsApp
Text
Would you like to receive our newsletter by Email (usually monthly)? About special offers and new products
*
Yes
No
Where did you hear about the clinic?
Are you currently taking any medication or any supplements, including isotretinoin (Roaccutane), and antibiotics or other medicines that make skin more sensitive to sunlight?
*
Yes
No
Do you have any medical problems or are you recovering from any medical treatment or operation within the last 12 months?
*
Yes
No
Do you have any allergies including metals, rubber silicone? If so what are you allergic to?
*
Yes
No
If yes to the above, please specify the condition, the medication and or allergies:
Is there any possibility of pregnancy or are you breast feeding?
*
Yes
No
Have you seen your GP or a dermatologist about your skin?
*
Yes
No
Have you attended a skin clinic for a consultation in the past?
*
Yes
No
Please advise
Are you using any home care exfoliating skincare, such as AHAs, glycolic acid products, or retinol/tretinoin? If so, what are you using?
*
Have you had any redness, stinging, peeling or other reaction to retinol or acid products, and has your skin been diagnosed as sensitive, or with eczema, rosacea or dermatitis?
What is your current morning skin care regime? Please include any prescription skin products.
What is your current evening skin care regime?
Please advise which ZO Skin Health/pHformula products you are currently using and who recommended them. How long have you been using them?
Do you use a daily SPF?
*
Yes
No
Out of 5, where 5 is very much and 1 is not at all. How much does your skin bother you?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Can you explain why it bothers you?
Where 5 is very much and 1 is not at all. How much do you think it affects the following?
Your social life
Not at all
1
2
3
4
Very Much
5
1 is Not at all, 5 is Very Much
Your employment or role at work
Not at all
1
2
3
4
Very Much
5
1 is Not at all, 5 is Very Much
How much does it impact you psychologically
Not at all
1
2
3
4
Very Much
5
1 is Not at all, 5 is Very Much
Please advise which products you want to purchase and any other information you wish to share:
The information I have given is correct to the best of my knowledge, and I have not withheld any medical status or information. I will inform the skin practitioner if my skin or health changes.
*
Submit
Should be Empty: