Skin Health Form

Please complete this confidential form before your skin consultation. Your medical history, skin concerns, product use, diet and lifestyle can all affect the health of your skin and help us personalise your treatment recommendations.

Your details
Your health
Do you experience sinus issues?
Do you experience hay fever?
Do you suffer from yeast or urinary tract infections?
Product and treatment history
What skincare products are you currently using?
Have you ever had Botox or filler?
Have you ever had any facial laser treatments?
Do you use, or have you used, Roaccutane, prescription Vitamin A or a Vitamin A product such as retinol?
Your skin
Please select all areas of concern that apply.
General
How do you heal from a cut?
Do you participate in any rigorous physical activity?
Do you smoke, or have you been a smoker in the past?
Daily eating habits
Do you crave sugar or coffee?
Beverages
Digestion
Do you experience constipation?
Do you experience diarrhoea?
Do you experience bowel movements daily?
Stress
Describe your stress levels.
Sleep
Women only (if applicable)
Do you have regular periods?
Are you using any contraception?
Are you pregnant or breastfeeding?
Have you been diagnosed with any of the following?
Consent

Privacy statement: The skin history and health information provided in this form will be used by authorised staff to assess treatment suitability and recommend treatments and homecare products appropriate to your skin. Please review our privacy policy for further information about how personal information is handled.

By submitting this form, I confirm that the answers provided are correct to the best of my knowledge and that I have not withheld information that may be relevant to my treatment.