Beauty Consultation

Where * denotes a required field.

    Patient Profile

    Gender *

    Medical Assessment

    Do you have a history of the following medical conditions? *

    In the past 3 months have you been prescribed any the following medications? *

    Other Prescribed Medications

    Do you have allergies to any of the following? *

    In the past 3 months have you used any of the following topical medication/treatments? *

    In the past 3 months have you had any the following? *

    General Health Assessment

    Please tick the appropriate box below

    Do you smoke? *

    Do you drink alcohol? *

    Do you regularly have sunbeds/ sun exposure? *

    Do you primarily work? *

    Do you wear contact lens? *

    Do you consent to Before & After images to be taken and possibly used by the clinic for social media purposes? (Your identity will not be revealed) *