Consultation Form

Name *
Please tick the appropriate box below
Are you currently taking any medication prescribed by a GP or any other Practitioner? *
Are you currently taking any medication containing Vitamin A? *
Are you currently pregnant, planning pregnancy or breastfeeding? *
Are you attending a GP or any other Practitioner for any other condition? *
Do you suffer from any allergies? (Hay fever, Aspirin etc.) *
Please tick the appropriate box(s) below
What is your skin type?
Do you ever get any of the following?
Are you prone to any of the following?
What are your main skin concerns?
How sensitive is your skin? *
Do you have a history of the following?
What product range/s are you interested in?
To the best of my knowledge the above information is relevant & factually correct. *
(Images of your skin may be requested.)