Cosmetic Consult Form

Please complete the below form to start your booking process.

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

How did you hear about us?

If other, please detail.

What are your current skin concerns

What is your primary goal for this consultation?

Example: specific treatment, product recommendations, general skincare advice, etc

Have you had any cosmetic treatments for your skin the past?

Example: Peels, laser, injectables, microdermabrasion, facials; please also list the last time you had treatments

Have you had a previous reactions/sensitivity to products or treatments? If yes, please list

What skincare are you currently using?

Please list brand names eg. La Roche Posay Toleraine Cleanser & Cicaplast Baume

Do you take any regular medications or supplements?

Do you have any medicine/drug allergies?

Do you ever wear any fake tan?

Yes

Is there anything else you would like to share with us?