Please compete thisSkin Consultation form before your appointment date.
The information you provide is confidential. If you have any questions, or difficulties completing it, please contact me by email or on 07557997653

Skin Consultation Form

Your Name(Required)

First Last

Please provide your Email address, if you have one

Best Contact Number(Required)

Address(Required)

Address Town Postcode

Do any of the following apply to you? Please select all that apply, or select None (at the bottom of the list)(Required)

Autoimmune disease

Asthma

Allergies

Blood disorder

Cancer (now)

Cancer treatment in the last 6 months or ongoing treatment

Cold Sores

Diabetes

Epilepsy

Eczema or Psoriasis

Eye problems (e.g. Styes, Blepharitis, Conjuntavitis, Dry Eyes, Watery Eyes)

Eye or Eyelid surgery in the last 6 months

Hay Fever

Hormone Imbalance, or Polycystic Ovary Syndrome (PCOS)

Heart Condition or Pacemaker

Hepatitis

High or Low Blood Pressure

Menopause (pre, during or post)

Pregnant, or trying to conceive

Rosacea, Facial Thread veins

Thrombosis

Thyroid conditions

Taking Roaccutane, or within the last 6 months

Taking prescribed medication

None

Have you had any of the following in the past 6 months. Select all that apply or None (at the bottom of the list)(Required)

Botox or fillers

Cosmetic surgery

Electrolysis or Laser hair removal on your face or bikini

Laser treatment

IPL or other types

Skin Peel

Microdermabrasion

Other

None

Are you on any medication? If yes please add more information in the box below(Required)

Yes

No

If you have selected any of the above, or there is anything else you want to mention, please add more details below

Skin Consultations - What concerns do you have with your skin?

Skin Consultations - Which brands and products do you use for your morning and evening skincare routine

Please add date(Required)

MM slash DD slash YYYY

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