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Consultation Form

Please complete the consultation form to assist our experts in correctly evaluating your needs and choosing the right treatment for you today.

Personal Details

*required fields

 Acne  Ageing  Alopecia  Blemished Skin  Dry Skin  Fine Lines and Wrinkles  Loss of Elasticity  Pigmentation  Scarring  Skin Imperfections  Sun Damage

Medical History

 Yes  No
 Yes  No
 Yes  No
 Yes  No Please note: If you are allergic to ASPIRIN then you are contraindicated to those products that contain salicylic acid.
 Yes  No

Skin History

 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
(The use of Roaccutane is contraindicated with topical vitamin A creams)
 Yes  No Psoriasis 
Keloid Scarring  
Eczema / Dermatitis  
Rosacea  
Herpes  
Facial surgical procedures 
Laser treatments eg IPL  
Microdermabrasion  
Chemical peels  
Botox / Fillers  
Laser hair removal  
Moles or sun spots removed  
Waxing  
Other skin treatments  
Please agree to the terms and conditions below:

To the best of my knowledge the above medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the skin expert of my current and ongoing health conditions.