Consultation Form

Medical Consent

















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)


Check the appropriate boxes below
Fine Lines
Wrinkles
Enlarged Pores
Pigmentation
Acne
Redness Rosacea
Scarring


Check the appropriate boxes below
Smoking
Sunbeds


Eczema
Psoriasis
Rosacea
Herpes Simplex


Comedones/Blackheads
Pustules/White Heads
Cystic Acne
Occasional Spots
Hormonal Breakouts
Never Breakout


Environ
Caudalie













Images of skin

Please upload an image for a member of our team to analyse your skin.