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Pre-
Treatment Consultation Form
Full Name
What are you skin cncerns?
*
Required
Acne
Acne Scarring
Large Pores
Dehydrated skin
Cysts
Nodules
Age Spots
Oily Skin
Melasma
Redness
Dull complexion
Blackheads
Excessive Facial Hair
Roseaca
Body Acne
Rough/Uneven Skin Texture
Milia
Sun Damage
Frequent Breakouts
Other
How would you describe your skin?
Choose an option
Are you currently under any medication, either topical or oral?
Please select all that apply:
*
Required
Do you smoke?
Are you prone to cold sores?
Do you Have an allergy to latex?
Do you tan regularly?
Are you claustraphobic?
Are you epeleptic?
Have you ever taken a reaction to a facial or body treatment before?
Have you received a face peel in the last 14 days?
Have you received any laser treatment in the last 4 weeks?
None of these apply
Please select the skin care products you're curently using
*
Required
Cleanser
Toner
Moisturiser
Facial Oil
Serum
SPF
Eyecream
Exfoliating Scrub
Self Tanner
Enzymes
Makeup
Other
Submit
Thank you for booking, see you soon!
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