Skin Consultation Personal DetailsName* First Last Address Address Line 1 Address Line 2 Town/City County Eircode Email* Phone*Occupation Referred By Date Of Birth* Day Month Year Your SkinCheck the areas you would like to improve with your skin* Colour Texture Freckles Wrinkles Eye Area Firmness Capilliaries Plumpness Smoothness Neck Area Decolletage Blackheads Breakouts Acne Premature Ageing Dryness Pore Size Congestion Scarring List the skincare products you are currently using*Have these achieved the results you want?* Yes No Do you use sunscreen on a daily basis?* Yes No Your BodyCheck the areas you would like more information on or are interested in* Celulite Body Sculpting/Firming Scarring/Pigmentation Alternative Hair Removal Weight Loss Stretch Marks Ingrown Hairs Heavy Calouses & Cracks On The Feet List the body care products you are currently using*Have these achieved the results you want?* Yes No Medical History We need this information to enable us to make treatment recommendations. We are committed to the safety and security of your data. Please view our privacy policy here for more information. Please tick the appropriate box belowDo You Smoke?* Yes No Have you in the past or present had any of the following problems? Epilepsy Diabetes Thyroid Heart Problems Cancer Hysterectomy Hormonal Imbalance Depression High Blood Pressure Low Blood Pressure Other If other please provide further information Have you had plastic surgery?* Yes No Date of surgery Description of Surgery*Surgeon's Name Are you currently using Retin-A, Retinol, AHA or any peeling agent?* Yes No If yes please please provide further information How long, Strength, Results.Do you suffer from claustrophobia or anxiety?* Yes No Have you any known allergies to: Cosmetics, Food, Medication, Animals, Pollens or Metals?* Yes No If yes please please provide further information Do you have a tendency to keloid scar?* Yes No Have you had a skin peel in the past 2 years?* Yes No If yes please please provide further information Brand, Results. MedicationHave you been under a physicians care during the past 3 years?* Yes No Are you currently taking medication?* Yes No Please list all medications that you are currently takingName & How long have you been taking it.Are you currently taking accutane or roaccutane?* Yes No If yes please please provide further information How long have you been taking it.Are you currently taking Dietary or Herbal Supplements or Vitamins?* Yes No If yes please please provide further information Name & How long have you been taking it. Images Of Skin Please upload the following images of your face for a member of our team to analyse your skin and make skincare recommendationsFront*Max. file size: 5 MB.Left*Max. file size: 5 MB.Right*Max. file size: 5 MB. Dietary DetailsHow much water would you drink per day?* Contacting You Let us know the best time to contact you.Days we can contact youMondayTuesdayWednesdayThursdayFridayTimes we can contact you5:30pm6:00pm6:30pm7:00pm7:30pmDeclaration* I hereby state that I have given the correct information above. I consent to Michelle's Skin & Beauty Clinic processing the personal and sensitive data submitted on this form for the purpose of providing a skin consultation to me. I understand that my data will be processed in line with Michelle's Skin & Beauty Clinic's Privacy Policy. Δ