Form

John & Associates

Skin Health Consultation Form
Please Provide As Much Information As Possible To Allow Us To Provide A Targeted Skin Solution Designed To Help You Reach Your Skin Goals.
Name*

First NameSurname Name
Work/Mobile Number? *
Please enter a valid phone number.
Home Tel Number*
(Please enter a valid phone number).
Email Address *
(example@example.com)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth

MonthDayYear
Date
What Is Your Occupation?
How Did You Find Us?

RecommendationWebsiteFacebookInstagramAdvertisingReferralInternetWopentake
Your Skin

Please Provide As Much Information As Possible.
What Do You Want To Get From This Consultation?
What Is Your Skin Care Goal?
What Concerns Do You Currently Have With Your Skin:

Lines/WrinklesDrynessUneven/Rough TextureAge SpotsDehydrationDark Pigmented AreasLight Pigmented AreasExcessive OilContinous BreakoutsOccasional BreakoutsInflammation
Red Veins/ Broken CapillariesThin/ Fragile SkinSensitization/RednessDermatitisPsoriasisEczemaRosaceaAcneAcne ScarringWhiteheadsBlackheadsEnlarged PoresProne To Scaring
Additional Information:
Please Share With Us Some Photos Of Your Main Areas Of Concern, This Will Help Us Prescribe The Best Treatment For You Prier To Your Consultation:
How Long Have Your Skin Concerns Been A Problem For?
What Have You Tried In The Past?
Tell Us About Your Current Skin Care Routine:
(Example- Cleanser, Toner, Exfoliator, Mask, Creams, Serums, Eye Creams, SPF. Use AM Or/And Pm.)
What Results Are You Seeing?
Is There An Occasion Or Deadline That You Are Working To?
How Much Are You Currently Investing In Your Skin Care Regime?
Is It A Temporary Fix That You're After Or A Long Term Solution?
Are You Ready To Change Your Current Skin Care Routine?
Do You Or Have Used Accutane, Glycolic Acid, Lactic Acid, Retinol, Tretinoin or Other Vitamin A Products?

Yes, Currently UsingYes, But Not Within 30 DaysYes, But Not Within 6 MonthsNo
Have You Had A Facial Or Skin Treatment Before?

YesNo
If Yes, What Facials And Skin Treatments Have You Previously Used To Help Your Skin Concerns?
(Example- Manual Facials, Electrical Facials, Skin Peels, Microdermabrasion, Laser Treatments, Micro Needling)
Have You Recently Been Exposed To The Sun Or Used Tanning Beds:

NoYes
Do You Spend Much Time Outside Exposed To The Elements?

Hardly Ever1 Hour Per Day2-3 Hours Per Day4-6 Hours Per DayMore Than 6 Hours Per Day
Your Health

Please Provide As Much Information As Possible.
Are You Currently Under Medical Care?

YesNo
Are You Currently Taking Any Medication?

YesNo
If Answered Yes To The Following Questions Please Provide Details Here:
Are You Currently Taking Any Vitamins Or Skin Supplements

YesNo
If Answered Yes To The Following Questions Please Provide Details Here:
Relevant Medical History:

Recent Surgery (Within The Last Year)Skin CancerEczemaPsoriasisRecent Treatments (Botox and/or Fillers)Rosacea (Active)Hormonal ImbalanceAutoimmune Disease
DermatitisDiabetes (Type 1/ Type 2)High/Low Blood PressureCold SoresThyroid ImbalanceEpilepsyHeart ConditionsMetal Plates / PinsSunburn (In Area)
Are You Currently Pregnant Or Breast Feeding

YesNo
Do You Have Any Allergies?

YesNo
If Answered Yes To The Following Questions Please Provide Details Here:
Gluten, Dairy, Latex, Cosmetics, Other
Do You Have Any Allergies To Aspirin ?

YesNo
Life Style

Please Provide As Much Information As Possible.
Do You Currently Smoke?

YesNo
Have You Ever Smoked?

YesNo
What Is Your Weekly Alcohol Consumption?

NeverOccasionallyLess Than 14 Units A WeekMore Than 14 Units A Week
Are You:

VeganVegetarianPescetarianNone Of The Above
Activity Levels :

Hardly Ever1 Hour Per Day2-3 Hours Per Day4-6 Hours Per DayMore Than 6 Hours Per Day
I Declare I Have Disclosed All Necessary Information In Order That A Treatment Plan Can Be Put Together Safely For Me. I Give Permission To Be Contacted To Book A Skin Consultation.
Please Provide A Signature Here:*

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John & Associates

Please Provide As Much Information As Possible To Allow Us To Provide A Targeted Skin Solution Designed To Help You Reach Your Skin Goals.

Your Skin

Your Health

Life Style