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ONLINE TREATMENT PLAN

To book your 'Online Personal Treatment Plan' please complete the form below.

Products & Treatments will be prescribed to suit your individual skin concerns.

(Treatment Plans cost £25.00 which is fully redeemable against any 'RegimA' product purchased through SkinFit).

Consultation Form

Personal Details:

First Name

Last Name

Address

Postcode

Date of Birth

Contact Number

Occupation

Skin Description (Type, Colour & Characteristics):

Please tick where appropriate

White - Always Burn, Never Tan, Blue Eyes, Blond or Red Hair

White - Usually Burn, Sometimes Tan, Light Skin and Hair

White - Sometimes Burn, Tan, Medium Skin Colour

Olive - Rarely Burn, Tan Well, Brown Eyes, Darker Skin

Brown - Rarely Burn, Deeply Tan

Black - Never Burn, Deep Pigmentation, Brown Eyes

Type:

Dry Skin

Normal Skin

Oily Skin

Oily T-Panel

Breakouts:

Acne

Acne Rosacea

Few Pimples

Hormonal

Sensitivity:

Normal

Sensitive

Very Sensitive

Skin History

Please tick where appropriate

Prone:

Acne

Acne Scarring

Body Scarring

Keloid Scarring

Eczema

Pigmentation

Psoriasis

Details (Please state area)

Treatments (Past & Present)

Chemical Peels - AHA

AHA's - Retinol

Efudix

Cortisone

Dermabraision

Roaccutane

Laser Treatment

Waxing - Wax

Other

Details (Please state date of treatments areas)

Current skincare regime?

Details

General Health

Please tick where appropriate

Alcohol

Allergies

Breast Feeding

Diabetes

Heart Disease

Hormone Problems

Medication

Pregnant

Skin Cancer

Skin Disorder

Smoker

Special Diet

Thyroid Problems

Details (Please state areas)

Concerns, Expectations & Additional Information

Details

Declaration

By ticking the box below, I acknowledge that the above information is correct and I am aware that no warranty or guarantee is given regarding the result of any treatment or the products used in such treatment.

Initials

Date

I declare that the information I’ve provided is accurate & complete

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Back

ONLINE TREATMENT PLAN

To book your 'Online Personal Treatment Plan' please complete the form below.

Products & Treatments will be prescribed to suit your individual skin concerns.

(Treatment Plans cost £25.00 which is fully redeemable against any 'RegimA' product purchased through SkinFit).

Consultation Form

Personal Details:

Skin Description (Type, Colour & Characteristics):

Please tick where appropriate

Type:

Breakouts:

Sensitivity:

Skin History

Please tick where appropriate

Prone:

Treatments (Past & Present)

Current skincare regime?

General Health

Please tick where appropriate

Concerns, Expectations & Additional Information

Declaration

By ticking the box below, I acknowledge that the above information is correct and I am aware that no warranty or guarantee is given regarding the result of any treatment or the products used in such treatment.

@skinfituk