DMK Skin Consultation - Michelle's Skin & Beauty Clinic

Personal Details

Name*

First Last

Address

Address Line 1 Address Line 2 Town/City County Eircode

Email*

Phone*

Occupation

Referred By

Date Of Birth*

Your Skin

Check the areas you would like to improve with your skin*

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 Body

Check the areas you would like more information on or are interested in*

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 below

Do You Smoke?*

Yes
No

Have you in the past or present had any of the following problems?

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.

Medication

Have 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 taking

Name & 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 recommendations

Front*

Max. file size: 5 MB.

Left*

Max. file size: 5 MB.

Right*

Max. file size: 5 MB.

Dietary Details

How much water would you drink per day?*

Contacting You

Let us know the best time to contact you.

Days we can contact you

Times we can contact you

Declaration*

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.