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Online Skin Consultation Form

Some products in our store are password protected as they require you to fill out our Consultation Form before purchase, once you have filled out the form we will send you the password. If you are unsure which products are best for your skin type, please also feel free to fill out the form and we will get back to you with our expert advice!

    Contact Details

    Name

    Email

    Phone Number

    Date of Birth

    Address

    1. PLEASE ANSWER THE FOLLOWING HEALTH QUESTIONS:

    Are you prone to any of the following?
    Psoriasis
    Eczema/Dermatitis
    Rosacea
    Keloid Scarring
    Herpes Simplex

    If you are, where and how long?

    Please indicate, are you or do you have any of the following?
    Pregnant
    Pacemaker
    Porphyria
    Diabetic*
    Cardiac Irregularities*
    Metal Plate/Pins
    Radiotherapy*
    Chemotherapy*
    Moles or Sun Spots Removed*
    History Thrombosis/Embolism*
    Circulatory Disorders*
    Multiple Sclerosis*

    These conditions are contraindicated to the Environ® DF Ionzyme® electrical treatments.
    *These require doctors consent

    Any other medical conditions?

    Any known allergies?

    Sonophoresis Caution:

    Hearing implants
    Tinitus

    Have you been treated with any of the following?
    Hormone Replacement Therapy
    Bioidentical Hormone Replacement Therapy
    Contraceptive Pill
    Topical Corticosteroids
    Oral Corticosteroids
    Topical Antibiotics
    Oral Antibiotics
    Topical Vitamin A (Retin A)
    Roaccutane
    Acne Medication (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)
    Blood Thinning Medication (e.g. Warfarin)

    Any other medication?

    If you have answered yes to any of the above, please state when and how long for:

    Please indicate if you are having or have had any of the following:

    CST (Immediately after treatment)
    IPL (Immediately after treatment)
    Laser Treatments (Wait 2 weeks)
    Microdermabrasion (Immediately after treatment)
    Electrolysis (Wait 2-3 days)
    Facial Waxing
    Botox (Wait 2 weeks)
    Fillers (Consult Practitioner)

    Other skincare treatments:

    If you have answered yes to any of the above, please state when and where:

    2. YOUR CONCERNS AND SKIN TYPE:
    Tell us - what are your main concerns?    Tick all that apply.











    Please tell us where on your face you are noticing these concerns:

    Tell us which vitamins and supplements you take, and do you take any for your skin?

    Skin Care and Make-up Routine
    Please tick if you use the products, and then specify which brand and products you use.















    3. YOU AND YOUR LIFESTYLE
    How do your cheeks look/feel?




    How does your T-Zone look/feel?




    How does your Eye Area look/feel?




    Describe the environment that your skin lives in.Tick all that apply.





    What kind of sun exposure do you get?




    On average how many hours of sleep do you get a night?




    How would you describe your stress levels?




    Tell us about your diet and lifestyle.

    Oily Fish:

    Fruit & Veg:

    Water Intake:

    Nuts & Seeds:

    Refined Sugar:

    Are you a Smoker?

    Tea/Coffee:

    Alcohol:

    Do you follow any diets?

    Are you Vegetarian?

    Are you Vegan?

    Do you currently Breast Feed?

    4. LET'S RECAP:

    Your main concern is:

    Your skin type is:

    Your skin goals are:

    We recommend you take some photos of your skin so that you can see the before and after effect.

    Your Personal Information

    Except for where you have separately granted Tina's Skin, Nail & Beauty permission to store and process your before and after photographs and face scan data, Tina's Skin, Nail & Beauty itself does not store or process your other personal and medical data as captured in this form - please liaise with the salon direct to understand its arrangements for data security and compliance with data legislation.

    TO THE BEST OF MY KNOWLEDGE THE MEDICAL INFORMATION I HAVE SUPPLIED IN THIS FORM IS RELEVANT AND FACTUALLY CORRECT

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