Name *
E-Mail *
Address
Phone
Occupation
Date of birth
Does your skin feel dry or tight even after a shower?
At what time of the day does your skin feel/look the oiliest (if this applies to you). Before midday or afternoon?
What skin type do you think you have? DryNormalOilySensitiveCombination
What skin conditions do you want to improve?
Oilyness
Pigmentation
Sensitivity
Dehydration
Redness
Psoriasis / Eczema
Rosacea
Acne
Broken capillaries
Ageing
Premature ageing
Please specify any conditions not listed above
Please tick if you suffer (or have suffered) from any of the following:
Eczema / Dermatitis / Psoriasis
Dysfunctions of nervous system
Herpes (cold sores)
Skin cancer
Thrombosis / Embolism
Hormonal imbalances
Diabetes
Metal implants
Blood disorders
Epilepsy
Allergies including skin sensitivity
High / low blood pressure
Pacemaker
Claustrophobia
Circulatory Disorders
Loss of tactile sensation
Warts
Trichotillomania
Dry eye syndrome
Asthma
Hypertrophic or Keloid scarring
If any of the above have ticked, please give details
Do you currently have any medical conditions not listed above? (if yes, please give details)
List any medications, supplements or vitamins you take regularly
Do you take Accutane? -YesNo
Have you had radiation or chemotherapy treatment in the past 12 months? -YesNo
Have you had recent surgery (in the last 12 months) on the area to be treated?
Are you currently pregnant, trying to become pregnant or breastfeeding? -YesNo
Do you wear contact lenses? -YesNo
Do you smoke? -YesNo
Do you exercise regularly? -YesNo
Do you follow a restricted diet? -YesNo
How much plain water do you consume daily?
How many caffeinated beverages do you drink daily?
How many alcoholic beverages do you consume weekly?
Rate your overall stress levels: -Low stressLow-medium stressMedium stressHigh stress
What skin care products are you currently using on your face (select all that apply)?
Soap
Eye products
Cleanser
Serums
Toner
Masque
Moisturiser
Exfoliant
Are you currently using any products that contain the following ingredients?
Glycolic acid
Lactic acid
Salicylic acid
Vitamin A derivatives (i.e. Retinol)
Do you use sunscreen every day? -YesNo
Do you use Retin A, Renova, Adapalene or other prescription skin care products? (if yes, please give details)
Have you had any cosmetic injectable treatments in the area to be treated in the past three months? (if yes, please give details)
Have you had any chemical peels, microdermabrasion or light therapy in the past month in the area to be treated? (if yes, please give details)
What are you hoping to achieve from your treatment today?
Do you have any special requirements for your treatment?
Your best time for a FaceTime of phone call online consultation? Morning before 9amBetween 9-11am1pm - 4pmAfter 6pm
I certify that all of the information I have given on this form is accurate.
