Skin Consultation Personal DetailsName* First Last Email* Phone*Date Of Birth* Day Month Year Medical Details 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 belowHave you had any recent illnesses?* Yes No If yes please please provide further information Are you taking any of the following treatments / medications?* Topical or Oral Cortisone / Prescribed skin treatment Topical or Oral Antibiotics HRT Contraceptive Pill None of the Above Are you currently taking any medication prescribed by a GP or any other practitioner?* Yes No If yes please please provide further information Are you currently taking any medication containing vitamin A?* Yes No If yes please please provide further information Are you currently pregnant, planning pregnancy or breastfeeding?* Yes No If yes please please provide further information Are you attending any GP or other practitioner for any other conditions?* Yes No If yes please please provide further information Do you have any allergies? e.g. Aspirin, allergies to ingredients in products?* Yes No If yes please please provide further information Dietary DetailsHow would you describe your diet?*How much water would you drink per day?* How much Alcohol would you consume per week?* Skin Questionnaire Please tick the appropriate boxes belowWhat is your skin type?* Dry (e.g. Tight, Dull & Flakey) Oily (e.g. Breakouts, Blackheads & Shiney) Combination (e.g. Dry Cheeks, Oily T-Zone) Normal (e.g. Balanced & Smooth) What are your main skin concerns?* Fine Lines Wrinkles Enlarged Pores Pigmentation Acne Redness Rosacea Uneven Skin Tone Do you have a history of the following?* Smoking Sunbeds None of the above How sensitive would your skin be?* Not Sensitive Mild Moderate Very Sensitive Are your prone to or currently have the following?* Eczema Psoriasis Rosacea Herpes Simplex None of the above Do you get any of the following?* Comedones / Blackheads Pustules / White Heads Cystic Acne Occasional Spots Hormonal Breakouts Never Breakout Your Current Skincare Routine Please give details in the appropriate boxes belowCleanse*Toner*Moisturiser*Mask*Eye Cream*Supplements*What skin care products are you currently using?*What are your skincare goals/what would you like to achieve?* 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.Right Side*Max. file size: 5 MB.Left Side*Max. file size: 5 MB. 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 Privacy Policy. Δ
