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Medical Grade Skin Care Questionaire

The products that we sell are medical grade. It is important that you are prescribed the correct skin products for your individual skin type and concerns.

We offer free of charge skin consultations in our rooms and would like to extend this offer to you. These appointments are very thorough and include a Visia Skin Analysis which provides you with a true picture of your skin’s health.

If you cannot attend an appointment at our rooms, please complete the following to start your skincare consultation with our expert skin specialists.

Once completed and you have been assessed for suitability by our expert specialists, you will receive product recommendations in an email.

Please note, online consultations are approved Mon-Fri 9-5pm. If completed after 3pm then you will be assessed on the next working day.

* = required information

About You

Title (Mr, Mrs, Miss, Ms, etc.)

First Name *

Last Name *

Date of Birth *


Line 1 *

Line 2

Town *

County *


Postcode *

Contact Information

Email Address *

Confirm Email Address *

Telephone *

Preferred contact method EmailPhone

Medical History

Do you have any Medical Conditions? * YESNO

If yes, please provide details

Are you taking any medication? * YESNO

If yes, please provide details

Are you taking any supplements? * YESNO

If yes, please provide details

Do have any allergies? * YESNO

If yes, please provide details

Are you allergic to nuts? * YESNO

Are you currently taking aspirin? * YESNO

Are you currently pregnant or breastfeeding? * YESNO

Your Skin

Do you have any of the following skin conditions? PsoriasisEczemaRosaceaAcne

Other (specify)

Have you ever experienced skin sensitivity to any products or facial treatments? * YESNO

Have you had any advanced facial treatments in the last 6 months? Laser IPL PeelsMicrodermabrasion InjectablesMicro needling

Other (specify)

Do you have any previous history of skin cancer? * YESNO

Would you burn within 20 minutes in the sun without SPF? * YESNO

What is your skin type? * Very FairFairCream/WhiteOliveDark BrownBlack

How do you find your skin? * OilyCombinationSensitiveDryNormal

Please state your skin concerns (if any)

Previous Vitamin A Use

Have you used prescription vitamin A before? * YESNO

If so, for how long?? *

Please give details of the results you experienced *

Your Concerns

What are your main concerns?

How can we help you today?


I confirm to the best of my knowledge that the answers given are correct and I have not withheld any information for the use products. I understand that results cannot be guaranteed. YES

Once your consultation and account has been approved, you will be able to browse and buy products from the website. These categories are exclusively available to our approved clients.