Free Consultation


Your Name*

Your Email*

Your Mobile*

Skin Type*

Skin Sensitivity*

Do you have Allergies / Intolerance (e.g Aspirin)*

Please Specify
Have you had any facial surgery including Botox or fillers? If so when did you have these?*

When & Where
Have had any facial hair removal, if so when? *

When & Where
Have you ever had any laser treatments? *

When & Where
Do you have any skin conditions, including rosacaea, eczema, psoriasis? *

Do you have or have you ever suffered from Rosacea? *

Have you had any of the following? *

Botox/Fillers (last 2 weeks)Microdermabrasion (last 2 weeks)WaxingChemical Peal (last 2 weeks)Moles or sun spot removedNone of the Above

Other Skin Care Treatments? *

Facials? *

Are you pregnant, breastfeeding or trying?*




Pacemaker / cardiac irregularities*

Facial Metal Implants / Excess Fillings*


Have you had any recent illnesses *

Are you taking Any of the Following? *

Topical or Oral Cortisone / Prescribed skin treatmentTopical or Oral AntibioticsHRTContraceptive PillNone of the Above

Are you currently taking any medication? *

How would you describe your diet? *

How much water would you drink per day?*

How much Alcohol would you consume per week?*

Have you had any other skin treatments?*

Please Specify
Are you currently taking any supplements? If so please state?*

What Makeup brands are you currently using?*

What changes would you like to see in your skin?*

AM Routine*

PM Routine*

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