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Sign In
My Account
Cart
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Home
About
Meet the Team
The Beauty Rooms Blog
Skincare
Alumier Skin Treatments
Advanced Skin Treatments
Beauty
Nails / Make Up / Brows & Lashes
Hair Removal / Waxing
Body / Tanning / Massage
Bridal
Shop
Alumier MD Skincare
Gift Vouchers
Offers
Special Offers
Membership Packages
Course of Treatments
Consultation Form
Book Now
Contact
Skincare and Beauty Salon in Ballyshannon, Co. Donegal
Consultation Form
Name
*
First Name
Last Name
Address
*
Date of Birth
*
Telephone
*
Email Address
*
MEDICAL CONSENT
Please tick the appropriate box below
Are you currently taking any medication prescribed by a GP or any other Practitioner?
*
No
Yes
If Yes please provide further information
Are you currently taking any medication containing Vitamin A?
*
No
Yes
If Yes please provide further information
Are you currently pregnant, planning pregnancy or breastfeeding?
*
No
Yes
If Yes please provide further information
Are you attending a GP or any other Practitioner for any other condition?
*
No
Yes
If Yes please provide further information
Do you suffer from any allergies? (Hay fever, Aspirin etc.)
*
No
Yes
If Yes please provide further information
SKIN QUESTIONNAIRE
Please tick the appropriate box(s) below
What is your skin type?
Dry (dull, flakey, tight)
Oily (comedones /blackheads, shiny, breakouts)
Combination (e.g. dry cheeks, oily t-zone)
Sensitive (prone to redness, itchy patches, broken capillaries)
Do you ever get any of the following?
Breakouts (Hormonal?)
Comedones (Blackheads)
Cystic Acne
Never breakout
Thread veins/redness
Milia
Dry patches
Are you prone to any of the following?
Eczema
Psoriasis
Rosacea
Herpes Simplex
What are your main skin concerns?
Fine lines
Enlarged pores
Pigmentation
Acne
Wrinkles
Scarring
Redness
Rosacea
Uneven skin tone
How sensitive is your skin?
*
Mild
Moderate
Extremely sensitive
Not sensitive at all
Do you have a history of the following?
Smoking
Sunbeds
What is your current skincare regime?
*
What are your skincare goals?
*
What product range/s are you interested in?
Advanced Nutrition Programme
Alumier MD
Environ
Jane Iredale
To the best of my knowledge the above information is relevant & factually correct.
*
(Images of your skin may be requested.)
Yes
No
Thank you!