Skin Assessment
Complete form to help with our assessment.
What skin concern(s) would you like us to assess and provide treatment options for?
*
Pigmentation / Dark Spots
Eczema / Dry or Itchy Skin
Rosacea / Redness & Sensitivity
Skin Glow / Brightening & Anti-aging
Not Sure, help me decide
Other
What skin area(s) are affected?
*
Face
Neck
Chest
Back
Hands
Arms
Legs
Other
How severe is it today?
*
Mild
Moderate
Severe
Unsure
Upload pictures of affected area(s)
Browse Files
Drag and drop files here
Choose a file
Neutral lighting, front/left/right, close‑up of concern.
Cancel
of
What is your skin type?
*
Dry
Oily
Combination
Normal
Sensitive
Unsure
What is your primary goal in your words?
Please verify that you are human
*
Back
Next
Save
Medical History
Please complete to help us assess relevant products for you.
What's the age?
*
Are you pregnant or breastfeeding?
Yes
No
Planning
Not Applicable
Do you have the following medical conditions
*
Liver disease
Kidney disease
Diabetes
Autoimmune
Thyroid
Psoriasis
Acne
None
Other
What allergies or sensitivities fo you have? (Include skincare, fragrances, antibiotics, lanolin, nuts, etc.)
What current medications/supplements do you take? (Include oral isotretinoin, antibiotics, steroids, photosensitisers).
What topical actives have you used in last 6 months?
Hydroquinone
Tretinoin/retinoids
Azelaic acid
AHAs/BHAs
Benzoyl peroxide
Corticosteroids
Vitamin C
Niacinamide
Other
What procedures have you done in last 3 months?
Chemical peel
IPL
Microneedling Dermabrasion
None
Other
What lifestyle factors is applicable? (Smoking (cigs/day); Alcohol (units/week); Sun exposure (low/med/high); Regular SPF use (Y/N); Occupation )
Smoking (cigs/day); Alcohol (units/week); Sun exposure (low/med/high); Regular SPF use (Y/N); Occupation
Do you have any painful blisters, infected/oozing skin, fever, rapidly spreading rash, eye involvement, or sudden swelling?
*
Yes
No
Back
Next
Save
What type of pigmentation do you have - best guess?
Melasma
PIH - Post Inflammation Hyperpigmentation (after acne/eczema)
Sunspots (lentigines)
Freckles
Unknown
How long have you had this pigmentation?
*
< 3 months
3–12 months
> 1 year
Since pregnancy
Since medication (specify)
Since medication (specify)
Pattern & triggers
*
Sun/heat
Hormonal (pregnancy/OCP/HRT)
After inflammation/procedures
Fragrance/cosmetics
Unknown
Is this seasonal or heat worsening?
*
Yes
No
What are your past treatments & response?
Willing to avoid sun/heat & use SPF50 daily?
*
Yes
No
What is your tolerance for light peeling/retinoids?
*
Comfortable
Mild
Prefer very gentle
Not sure
Possible cause(s)?
Sun exposure
Hormonal (pregnancy, contraceptives, menopause)
Acne or injury (PIH)
Medications
Unknown
Other
Have you used pigmentation treatments before?
*
Hydroquinone
Tretinoin
Azelaic Acid
Kojic Acid
Alpha Arbutin
Tranexamic Acid (oral/topical)
Niacinamide
Botanicals (licorice, mulberry, vitamin C, etc.)
None of the above
Do you have or have you ever had
Hormonal therapy / Contraceptives
Thyroid disorder
PCOS
Diabetes
Liver disease
Kidney disease
Autoimmune disease
Cancer (current or past)
No medical conditions
Other
What's your main goal?
*
Fade dark spots
Even overall skin tone
Prevent recurrence
Other
Back
Next
Save
What type of eczema do you have?
*
Atopic
Hand
Nummular
Asteatotic
Contact (suspected)
Unknown
When did it start?
*
Childhood
Adult
Postpartum
Recent (<6 months)
Unknown
What are your current symptoms?
*
Dryness
Itch
Redness
Cracking
Weeping
Infection suspected (yellow crust/pus)
How often do you get flares?
*
Rare
Monthly
Weekly
Constant
What are the triggers?
*
Soaps/detergents
Fragrance
Wool
Stress
Cold/dry weather
Foods
Metals (nickel)
Unknown
What steroid treatment have you used?
*
None
Mild
Moderate
Potent
Unsure
What cream or emollients have you used?
*
Back
Next
Save
What ype of rosacea do you have?
Erythematotelangiectatic (redness/flush) Papulopustular (spots)
Phymatous (thickening)
Ocular
Unkown
What are the triggers?
*
Heat
Hot drinks/spicy
Alcohol
Exercise
Sun
Stress Skincare products
Unknown
What are your symptoms?
*
Burning/stinging
Visible vessels
Pustules
Eye irritation
Flushing episodes
Stress Skincare products
Unknown
How often do you get this?
*
Rare
Occasional
Daily
Multiple times/day
Stress
Skincare products
Unknown
What treatments have you used in the past?
*
(e.g., metronidazole, azelaic, ivermectin, brimonidine, lasers/IPL)
How sensitive is your skin?
*
Very sensitive
Moderately sensitive
Robust
Unknown
Back
Next
Save
What are your top goals?
Brighter tone
Fine lines
Texture/pores
Hydration
Firmness
Preventive routine
How many steps are you happy with?
1–2 steps
3–4 steps
Full routine OK
How often do you use SPF?
*
Daily
Often
Rarely
Never
Back
Next
Save
Contact details
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Gender
*
Please Select
Male
Female
N/A
Date of Birth
*
-
Day
-
Month
Year
Date
Additional information to help your assessment
Book Online Assessment
*
Consent
*
By submitting this form, you agree that our prescribers may contact you regarding your assessment, prescriptions, and care. This is essential. We would also need to send updates I’d also like to receive updates, offers, and educational content from the clinic. You can unsubscribe anytime.
Consultation Fee
prev
next
( X )
Consultation Deposit
This is a one time fee for assessment and consultation.
£
25.00
Payment Details (via Stripe)
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Save
Submit
Should be Empty: