Consultation Form Personal DetailsYour Name* Date Of Birth* DD slash MM slash YYYY Your Email* Your Phone*Medical ConsentAre 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 If yes please provide further information If yes please provide further information Are you currently pregnant, planning pregnancy or breastfeeding? No Yes Do you have any allergies? E.g. Aspirin, allergies to ingredients in products? No Yes If yes please provide further information If yes please provide further information Are you attending any GP or other practitioner for any other conditions? Skin Questionaire Please tick the appropriate box(s) belowWhat 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? Fine Lines Wrinkles Enlarged Pores Pigmentation Acne Redness Rosacea Scarring Do you have a history of the following? Smoking Sunbeds How sensitive would your skin be? Mild Moderate Very Sensitive Not Sensitive Are your prone to or currently have the following? Eczema Psoriasis Rosacea Herpes Simplex Do you get any of the following? Comedones/Blackheads Pustules/White Heads Cystic Acne Occasional Spots Hormonal Breakouts Never Breakout What products are you looking for (Or Recommended) ? Juliette Armand Alumier MD Not sure What is your current skincare routine? Please complete each each belowCleanse Toner Moisturiser Mask Eye Cream What is your main skin care concern? Lines Sun damage Acne Scarring Veins Loose Skin Eye Area Pores What are your skincare goals/what would you like to achieve?Images of skinMax. file size: 1 MB.Please upload an image for a member of our team to analyse your skin (images should be less that 1 MB)