Where * denotes a required field.
Full Name *
Date of Birth *
Email Address *
Phone Number *
How did you hear about us?---Word of MouthSearch EngineNewspaperRadioTVFlyerOther
How did you hear about us?
Please tick the appropriate box below
Are you currently taking any medication prescribed by a GP or any other practitioner? *YesNo
Please provide further information:
Are you currently pregnant, planning pregnancy or breastfeeding? *YesNo
Are you currently using or have you used Accutane (isotretinoin) in the last six months? *YesNo
Please provide date last taken and prescribed dose:
Are you Diabetic? *YesNo
What type of Diabetes do you have?
Do you have a history of the following? SmokingSunbedsSunburnSkin Cancer/Cancer
On a scale of 1 to 10, 1 being very low and 10 being very high, what score would you give your current level of stress? *
Are you attending any GP or other practitioner for any other conditions? *YesNo
Do you have any known allergies? *YesNo
Please list any and all allergies you may have:
Do you take food supplements? *YesNo
What food supplements do you take:
How would you describe your skin? *Normal (e.g. Balanced & Smooth)Dry/Dehydrated (e.g. Tight, Dull, Flakey)Oily (e.g. Breakouts, Blackheads, Congestion, Shiney)Combination (e.g. Dry cheeks, Oily t-zone)
What are your main skin concerns? *Fine LinesWrinklesEnlarged PoresPigmentationAcne/BreakoutsRedness/Broken CapillariesRosaceaUneven Skin ToneSkin LaxityScaring
Do you notice your skin concern to be any worse at any time of the day/month/year? *YesNo
Are you prone to or have you ever had any of the following? EczemaPsoriasisRosaceaHerpes SimplexDermatitisAlopeciaNone of the above
Do you ever suffer with any of the following? Comedones/BlackheadsPustules/WhiteheadsCystic/Inflamed AcneHormonal BreakoutsMiliaNone of the above
Do you think your skin is sensitive? *YesNo
Please explain why you think this and whether or not you think you are sensitive to certain products or are just naturally sensitive:
How would you describe your diet on average? *PoorCould be betterModerateExcellent
Are you currently following a dietary plan? *YesNo
Do you wear false tan? *YesNo
Do you exercise/go to the gym? *YesNo
What products are you interested in/recommended? *AlumierMDCosmedixAdvanced Nutrition ProgramJane Iredale Mineral Makeup
What is your current skin care routine A.M and P.M? Please list any and all products you use including weekly treatments i.e. masks, exfoliators etc
How are these products treating your skin concerns? Have you seen an improvement?
Have you had skin treatments in the past? *YesNo
What skin treatments have you had?
Did these treatments make a difference? *YesNo
What services are you interested in? *Homecare ProgrammeIn-Clinic Treatments
Please upload recent and clear pictures of your skin so that your FitSkin Consultant can assess your concerns and more accurately prescribe your recommended skincare. If you are uploading pictures of your face please provide a picture of the front, left side and right side of the face.Upload at least 1 image (Max. 6MB per image) in one of the following formats: .jpg | .jpeg | .png
Do you have any other medical or non-medical conditions that you feel may be of importance to your FitSkin Consultant to accurately assess your concerns?
I hereby declare that the information provided is true and correct to the best of my knowledge.