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Online Treatment Plan

To book your 'Online Personal Treatment Plan' please complete the form below.
Products & Treatments will be advised to suit your individual skin concerns.
(Treatment Plans cost £15.00 which is fully redeemable against any 'SkinScription' products or Online Treatments purchased through our Shop or Booking System.

Consultation Form

Please give as much detail where possible to help us advise.

You will receive your Personal Treatment Plan within 48hrs of us receiving your completed form.

First Name

Last Name

Email

Date of Birth

Skin Description (Type, Colour & Characteristics):

White - Always Burn

White - Sometimes Burn

Olive - Rarely Burn

Mixed - Rarely Burn

Brown - Rarely Burn

Black - Never Burn

Other

Skin Type:

Dry Skin

Normal Skin

Oily Skin

Oily T-Zone

Breakouts:

Acne

Acne Roscea

Few Pimples

Hormonal

Discoloration/ Hyperpigmentation

Sensitivity:

Normal

Sensitive

Very Sensitive

Skin History : please choose where appropriate

Acne

Body Acne

Keloid Scarring

Pigmentation

Eczema

Psoriasis

Treatments ( Past & Present)

Chemical Peels AHA

AHAs/Retinol

Steroids

Dermabrasion

Roaccutane

Laser

Waxing

Other

Details and dates of treatment

Current Skincare Regimen

General Health: Please tick where appropriate

Alcohol

Allergies

Breastfeeding

Diabetes

Heart Disease

Hormonal issues

Medication

Pregnant

Skin Cancer

Smoker

Special Diet

Thyroid Problem

Details( please state below)

Concerns & Expectations & Additional Information

By ticking the box below, I acknowledge that the above information is correct and I am aware that no warranty or guarantee is given regarding the result of any treatment or the products used in such treatment.

Your Signature ( Add Initials)

Date

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Thanks for submitting! A Peronslised skin plan will be sent to your email within 48 hrs

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COMMUNITY

SUSTAINABILITY

© HDaestheticUK 2023 Company Number: 0121 454 1556

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