Consultation Form

Your Name (required)

Address (required)

Date Of Birth (required)

Your Email (required)

Your Phone(required)

Medical Consent

Are you currently taking any medication prescribed by a GP or any other practitioner NoYes

If yes please please provide further information

Are you currently taking any medication containing vitamin A? NoYes

If yes please please provide further information

Are you currently pregnant, planning pregnancy or breastfeeding? NoYes

If yes please please provide further information

Are you attending any GP or other practitioner for any other conditions?

Do you have any allergies? E.g. Aspirin, allergies to ingredients in products? NoYes

If yes please please provide further information

Skin Questionaire

Please tick the appropriate box(s) below
What us your skin type?
Dry (Eg Tight, dull & Flakey)
Oily (Eg Breakouts, Blackheads & Shiney)
Combination (Eg Dry Cheeks, Oily T-Zone)
Normal (Eg Balanced & Smooth)

What are your main skin concerns?
Check the appropriate boxes below
Fine Lines
Wrinkles
Enlarged Pores
Pigmentation
Acne
Redness Rosacea
Scarring

Do you have a history of the following?
Check the appropriate boxes below
Smoking
Sunbeds
How sensitive would your skin be?
Mild
Moderate
Very Sensitive
Not Sensitive

Are your prone to or currently have the following?
Eczema
Psoriasis
Rosacea
Herpes Simplex

Do you get any of the following?
Comedones/Blackheads
Pustules/White Heads
Cystic Acne
Occasional Spots
Hormonal Breakouts
Never Breakout

What products are you looking for (Or Recommended)
Environ
Alumier MD

What is your current skincare routine? Please complete each each below
Cleanse

Toner

Moisturiser

Mask

Eye Cream

What are your skincare goals/what would you like to achieve

Images of skin

Please upload an image for a member of our team to analyse your skin (images should be less that 1 MB)