FitSkin Consultation

Where * denotes a required field.

    Patient Profile

    Medical Assessment

    Please tick the appropriate box below

    Are you currently taking any medication prescribed by a GP or any other practitioner? *

    Are you currently pregnant, planning pregnancy or breastfeeding? *

    Are you currently using or have you used Accutane (isotretinoin) in the last six months? *

    Are you Diabetic? *

    Do you have a history of the following?

    Are you attending any GP or other practitioner for any other conditions? *

    Do you have any known allergies? *

    Do you take food supplements? *

    Skin Assessment

    What are your main skin concerns? *

    Do you notice your skin concern to be any worse at any time of the day/month/year? *

    Are you prone to or have you ever had any of the following?

    Do you ever suffer with any of the following?

    Do you think your skin is sensitive? *

    Are you currently following a dietary plan? *

    Do you wear false tan? *

    Do you exercise/go to the gym? *

    What products are you interested in/recommended? *

    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

    Have you had skin treatments in the past? *

    Did these treatments make a difference? *

    What services are you interested in? *

    Skin Images

    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

    File 1

    File 2

    File 3