To assess which skincare is best suited to you, please fill out this consultation form & attach any photos of your skin (optional) & send to revampaestheticsskincare@gmail.com with your name as the subject.

Date:
Name:

Date of Birth: 
Address:
Mobile Phone:

E-mail address:

Does your job require that you work outdoors? No Yes

What would you like to achieve with your skincare?

Your Skin Care
1 - Have you ever had a facial treatment before?

No Yes, when?

2 - Do you have any skin problems or concerns to your face or body?

No Yes
Specify:

3 - Have you ever had chemical peels, laser or microdermabrasion or other skin treatments? No Yes

In the last month? No Yes

If yes, what did you have?

4 - Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? No Yes
Please describe:

5 - Have you used any of these products in the last 3 months?  No Yes

6 - Have you used an acne medication? No Yes,

when? Which one?

7-  What skin care products are you currently using? (List brand where known)

8-  Have you recently used any self-tanning lotions, creams or treatments? No Yes, specify:

9- Have you used any of the following hair removal methods in the past six weeks on your face?

No  Yes, circle all that apply.

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories

10-  What areas of concern do you have regarding your: Skin:

(Please check any that apply and explain)
Eyes:
Dehydration, wrinkles, puffiness, dark circles Other:
Lips:
Dehydrated, cracked/chapped lips, Other:

Skin texture

11-  Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
If yes, please explain:

Cleanser - 

Exfoliant - 
Mask - 
Moisturiser - 

Serum -

Scrubs - 
Shower Gels or soap -
Body Lotions - 
SPF - 
Other - 

Makeup Products
Circle any that apply:
Breakouts/acne 
Blackheads/whiteheads 
Excessive oil/shine 
Rosacea 
Broken capillaries 
Redness/ruddiness 
Sun spot/liver spot/brown spot 
Uneven skin tone 
Sun damage 
Wrinkles/fine lines 
Dull/dry skin 
Flaky skin 
Dehydrated 
Other
Cosmetics 
Medicine 
Food 
Animals 
Sunscreens 
Iodine 
Pollen 
AHAs 
Fragrance 
Latex 
Drugs 

Female Clients Only:
12 - Are you taking oral contraceptives?  No  Yes
specify:

13 - Any recent changes to or from your contraceptive treatment?

No Yes
If so, what and when:

14- Are you pregnant or trying to become pregnant?  No  Yes

15-  Are you lactating?  No Yes

16- Any menopause problems? No Yes
specify:

17- Are you undergoing any hormone replacement therapy? No  Yes
specify:

Male Clients Only:
18-  What is your current shaving system?

Wet shave Electric 
19- Do you experience irritation from shaving? No Yes Ingrown hairs? No Yes

The following factors are potential triggers for breakouts & acne -

1. Diet, Allergies & Medication
2. Physical Health & Exercise
3. Mental health
4. Internal & External factors
5. Environmental triggers, including UV, pollution, pesticides
6. Toxic exposure to inflammatory chemicals, preservatives, irritatation of skincare/makeup.

Please use this space to complete answers where space was insufficient. Please include the number of the question & your concerns relating & any other information you want to specify or address.

Thankyou!