Online Skin Consultation

Please fill this form out in as much detail as possible. It will help paint a picture of what could be going on with your skin, enabling me to make the right recommendations for you.

Personal Details

First Name

Last Name

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Area Code

Phone Number

Today's Date

Age

Occupation

Medical History

Are you suffering from any of the following?

Infectious diseases (e.g., Impetigo)

Boils

Ringworm

Coldsore (Herpes Simplex)

Chicken Pox

Warts

Damaged skin (e.g., Sunburn)

Infectious eye problems (e.g., Conjunctivitis)

Scabies or other infestations

If you ticked any of the above, please provide notes here:

Any medication?

In the last 9 months, have you undergone any surgery? If yes, please specify below.

Any health problems, past and present?

List of any medication and supplements you are currently taking:

Allergies?

Lifestyle

Life style - sedentary? Exercise regime? Stress levels? How much water?

Do you follow a restricted diet - please give details

How much alcohol do you consume per week?

Do you smoke? If yes, how long for?

How many caffeinated beverages daily?

What does a typical day's food look like for you? Please list brands and include all snacks and drinks. As much information as possible.

What does a typical day look like for you? What do you do as soon as you wake up? Do you work from home or in an office? Do you get outdoors for fresh air and sunlight daily?

Skincare History

Current skincare routine including products?

Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatments? When?

Have you used Accutane, Retin A, Renova or any other prescription skin products in the last three months?

Are you currently using any products that contain Glycolic acid, Lactic acid, any Hydroxy acid product, Vitamin A derivatives and any exfoliation scrubs? If yes, which ones and by which brand?

Current Skin Concerns

What age did these problems occur?

Are your current skin problems getting more pronounced?

Yes

Have you received treatment for this problem before? If yes, when and what method?

Do you ever experience these conditions with your skin?

Flakiness

Tightness

Obvious dryness

Do you burn easily in moderate sunlight?

Yes

Do you blush easily when nervous?

Yes

Do you have a tendency to redness?

Yes

How does your skin feel on a daily basis?

Are you prone to cold sores?

Yes

Do you ever experience a burning/itching sensation on your skin?

Yes

Reactions & Final Questions

Are you currently having or due your period?

Yes

N/A

What are your skincare goals? How can I help you?

Confirmation

Your Email Address

Digital Signature (type your full name)