Online Skin Consultation

    Personal Details


    Medical Consent

    Please tick the appropriate box below

    Are you currently taking any medication prescribed by a GP or any other practitioner?
    YesNo
    If yes please please provide further information
    Are you currently taking any medication containing vitamin A?
    YesNo
    If yes please please provide further information
    Are you currently pregnant, planning pregnancy or breastfeeding?
    YesNo
    If yes please please provide further information
    Are you attending any GP or other practitioner for any other conditions?
    YesNo
    If yes please please provide further information
    Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?
    YesNo
    If yes please please provide further information


    Skin Questionaire

    Please tick the appropriate box(s) below

    What is your skin type?
    What are your main skin concerns?
    Do you have a history of the following?
    How sensitive would skin be?
    Are your prone to or currently have the following?
    Do you get any of the following?
    What products are you looking for (Or Recommended)?
    What is your current skincare routine? Please complete each below.


    Images of skin
    Please upload an image for a member of our team to analyse your skin.


    I agree I have given the correct information above.

     

    After sending the above form, you can book an appointment using next section.

    Book an Appointment

    When the booking has been made we will confirm your appointment by email.

    Newsletter

    By using this form, you agree with the storage and handling of your data by this web-site.

    logo footer

    © 2021 NATASHA BEAUTY THERAPY.