Name (required)
Email (required)
Date of Birth (required)
Telephone number (required)
Do you suffer from any medical conditions?
Do you have any allergies?
Are you taking any medications?
Have you taken any medications within the last 4 weeks?
Have you had increased sun exposure/tanning machines in the last 4 weeks?
Women of child-bearing age - are you pregnant or breastfeeding?
Describe your skin complaint?
What products are you currently using on your skin?
When did this skin problem first occur and what caused it?
What products have you tried before and have they helped?
I confirm this information is correct and consent to further treatment and advice.
