ONLINE SKIN QUESTIONNAIRE ONLINE SKIN QUESTIONNAIRE

Skin Consultation Form

About You

First Name
Last Name
Email Address
Phone Number
Preferred Method of Contact
Age Range
Do you have any known allergies or sensitivities (skin or otherwise)?

Your Skin Concerns

What are your top 1 - 3 skin concerns right now?
How long have you been experiencing these concerns?
Where are you experiencing these concerns?

Your Skin Goals

What would you most like to achieve with your skin?
Anything else not listed above?
Do you have any special events coming up you’re preparing for?
If yes, provide more details:

Your Current Routine

What skincare products are you currently using?
What skincare brand/s are you currently using?
How consistent are you with your routine?
Have you used professional skincare products before?
Have you had professional skin treatments before?
If yes, which ones?

Lifestyle Influences & Skin Factors

Are you currently taking any medications, supplements, or vitamins? If yes, please provide details:
How often do you wear SPF
Do you smoke cigarettes, vape, or use any other tobacco products?
Do you experience hormonal imbalances?

If yes, provide more details:
Please tick any of the following that apply to you:
Anything else we should know about your skin or lifestyle?

Your Preferences

Are you looking for:
Which best describes the results you are looking for?
If there is a budget you would like us to stick to, please provide more information here (include amount and frequency):
Would you be open to discussing your skin routine further by any of the following methods?
Image UploadIf you’d like, you can upload a photo of your skin to give our therapists a better visual understanding of your concerns. This step is completely optional, but it helps us create a more personalised and accurate skincare  and treatment plan for you.

Hit ‘Send’ and leave the rest to us. Your customised skin plan is on its way.