Online Skin Consultation Personal Details Name* Address* Date of Birth* Telephone Number* Email Address* Medical Consent Please tick the appropriate box below Are you currently taking any medication prescribed by a GP or any other practitioner NoYes If yes please please provide further information Are you currently taking any medication containing vitamin A? NoYes If yes please please provide further information Are you currently pregnant, planning pregnancy or breastfeeding? NoYes If yes please please provide further information Are you attending any GP or other practitioner for any other conditions? Do you have any allergies? E.g. Aspirin, allergies to ingredients in products? NoYes If yes please please provide further information Skin Questionaire Please tick the appropriate box(s) below What us your skin type? Dry (Eg Tight, dull & Flakey)Oily (Eg Breakouts, Blackheads & Shiney)Combination (Eg Dry Cheeks, Oily T-Zone)Normal (Eg Balanced & Smooth) What are your main skin concerns? Check the appropriate boxes below Fine LinesWrinklesEnlarged PoresPigmentationAcneRedness RosaceaUneven Skin ToneScarring Do you have a history of the following? Check the appropriate boxes below SmokingSunbeds How sensitive would skin be? MildModerateVery SensitiveNot Sensitive Are your prone to or currently have the following? EczemaPsoriasisRosaceaHerpes Simplex Do you get any of the following? Comedones/BlackheadsPustules/White HeadsCystic AcneOccasional SpotsHormonal BreakoutsNever Breakout What products are you looking for (Or Recommended)? EnvironCaudalie What is your current skincare routine? Please complete each each below Cleanse Toner Moisturiser Mask Eye Cream What are your skincare goals/what would you like to achieve Images of skin Please upload an image for a member of our team to analyse your skin. I agree I have given the correct information above.