Consultation Form


Medical Consent

Are you currently taking any medication prescribed by a GP or any other Practitioner?*

No
Yes

Are you currently taking any medication containing Vitamin A?*

No
Yes

Are you currently pregnant, planning pregnancy or breastfeeding?*

No
Yes

Are you attending a GP or any other Practitioner for any other condition?*

No
Yes

Do you suffer from any allergies? (Hay fever, Aspirin etc.)*

No
Yes

Skin Questionnaire

What is your skin type?

Dry (dull, flakey, tight)
Oily (comedones/blackheads, shiny, breakouts)
Combination (e.g. dry cheeks, oily t-zone)
Sensitive (prone to redness, itchy patches, broken capillaries)

Do you ever get any of the following?

Breakouts (Hormonal)
Comedones (Blackheads)
Cystic Acne
Never breakout
Thread veins/redness
Milia
Dry patches

Are you prone to any of the following?

Eczema
Psoriasis
Rosacea
Herpes Simplex

What are your main skin concerns?

Fine lines
Enlarged pores
Pigmentation
Acne
Wrinkles
Scarring
Redness
Rosacea
Uneven skin tone

How sensitive is your skin?*

Mild
Moderate
Extremely sensitive
Not sensitive at all

Do you have a history of the following?

Smoking
Sunbeds

What product range/s are you interested in?

Advanced Nutrition Programme
Alumier MD
Environ
Jane Iredale

To the best of my knowledge the above information is relevant and factually correct.*

Yes
No