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.