Name *
Address *
Date of Birth
Telephone Number *
E-Mail *
Are you currently taking any medication prescribed by a GP or any other practitioner ?NoYes
If yes please provide further information
Are you currently taking any medication containing vitamin A?NoYes
Are you currently pregnant, planning pregnancy or breastfeeding?NoYes
Are you attending any GP or other practitioner for any other conditions?
Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?NoYes
What is your skin type?
Check the appropriate boxes below
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?
Enlarged Pores
Pigmentation
Acne
Redness Rosacea
Uneven Skin Tone
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)?
Environ
Other
If ‘other’ which products ?
What is your current skincare routine? Please complete each each below
Cleanse
Toner
Moisturiser
Mask
Eye Cream
What are your skincare goals/what would you like to achieve
Please email an image for a member of our team to analyse your skin to rosiejandrews84@hotmail.com.
I agree I have given the correct information above. *
