Personal Information Name & Surname Email Phone Address Birthday How did you hear about us? Your Health Within the last year, have you had any health problems that have affected/ could affect your skin? YES/NO Please specify: List any medications, supplements, vitamins etc. (incl. oral contraception) that you take regularly Do you wear contact lenses? Yes No Do you have sinus problems? Yes No Do you have metal implants, pacemaker or piercings? Yes No Do you experience claustrophobia? Yes No Please list any allergies: Your Skin What are your specific skin concerns/challenges? What skincare products are you currently using? Soap Cleanser Toner Moisturizer Masque Exfoliant Eye Products Other Have you had chemical peels, microdermabrasion or resurfacing procedures in the last three months? Yes No Have you used Retin-A or prescription skin products in the last 90 days? Yes No Are you currently using any products containing the following ingredients? Glycolic Acid Lactic Acid Exfoliating Scrubs Hydroxy Acids Vitamin A derivatives Please indicate if any of the following apply to you: Pregnant Trying to become pregnant Lactating Pre-Menstrual Menstruating I confirm to my best knowledge that the answers I have given are correct and true, and that I have provided any information relevant to my treatment Send