Consultation

First Name

Last Name

Email

Address

Phone Number

Skin Type

If yes, please state the nature of the allergy

Do You Have Facial Surgical Procedures?

Do You Have Laser Hair Removal?

Do You Have Laser Treatments? e.g IPL

Have you had any of the following?

Botox/ Fillers (last 2 Wwks)

Microdermabrasion

Waxing

Chemical Peel (last 2 weeks)

Moles or sun spot removed

None of the above

Please list any other skin care treatments you have had in the last month?

Are you pregnant, trying or breast feeding?

Diabetic

Prophyria

Epilepsy

Pacemaker / cardiac irregularities

Facial Metal Implants / Excess Fillings

Smoker

Skin Conditions? e.g eczema, psoriasis

Do you have or have you ever suffered from Rosacea?

Have you had any recent illnesses

Are you taking Any of the Following?

Topical or Oral Cortisone / Prescribed skin treatment

Topical or Oral Antibiotics

HRT

Contraceptive Pill

None of the Above

How would you describe your diet?

How much water would you drink per day?

How would you describe your diet?

How much Alcohol would you consume per week?

What skin care brands are you currently using?

What Makeup brands are you currently using?

What changes would you like to see in your skin?

Images of your face and skin will help us with the process. Do you want to send photos now?

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Get in Touch

If you need any more information on any of our products or services. Please don't hesitate to get in contact today

Address. Anne St, Bailieborough, Co. Cavan, A82HD21

Email.

Phone. (042) 966 6622

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