Online Consultation Form

Please find our online consultation form below. This is a lengthy consultation form and it will likely take you 5-10 minutes to fill it in. As this treatment is carried out remotely under supervision, the more information you can provide prior to the video consultation/treatment the more personalised it will become. Thank you for taking the time to complete it.
  • DD slash MM slash YYYY
  • Hereditary History

  • Lifestyle

  • How would you describe yourself
  • Medical History / Medication

  • Roaccutane, Adapalene, Topical Antibiotics, Anti-fungal Nail Treatments, Topical Cortisone.
  • Heart disease, a pacemaker or valve replacement, metal implants, Menopause/peri-menopausal, Hepatitis, Oral Contraceptives
  • Your skincare

  • Cleansing, toner, moisturiser, mask, exfoliation, sunscreen?
  • Peels, microdermabrasion or dermaplanning, Injectables, Cosmetic surgery, Laser treatment, Skin needling, other relevant procedures. Have you, are you using Hydroquinone, Retin-a / Tretinoin or Alpha Hydroxy Acids?
  • Your skin goals

  • If you can cleanse your skin and tidy your hair away from your face.
    Drop files here or
    Max. file size: 256 MB.
    • The Fitzpatrick scale is a tool that places everyone into one of six groups. This is to estimate the risk to the skin of sun damage.
    • How would you describe your skin type
    • Special Cautions