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Eve Taylor Consultation Form
First name
Last name
D.O.B
Could you be/are you pregnant or lactating
Yes
No
Do you have any of the condtions listed blow
Cancer or history of cancer
Diabetes
Pregnant or lactating
Claustrophobia
Migrains/headaches
Eczema
Skin disease
Lupus/autoimmune desiese
Shingles
Asthma
Allergies
Thrombosis
Heart condition
Hypo pigmentation
Polycystic overy syndrome
Melasma
Ever been diagnosed with melanoma
Hormone imbalance
HIV/AIDS/Hepatitis
Epilepsy
Do you have any health conditions not listed above
Yes
No
If yes please please state below
Skin Type
Normal
Dry/Dehydrated
Combination
Sensitive
Ageing
Skin Concerns
Acne
Break Outs
Black Heads
Large Pores
Pigmentation
Roseacea
Scaring
Please select any treatmens you have previously had
Fillers
Botox
Lazer treatment
Semi permanent makeup
Skin Peels/Microdermabrasion
Microcurrent facials
Dermaplaning
Microneedling
Other
If you have had any of the above treatments, or other treatments not listed above please state treatment below and when you had your treatment?
Are you using any of the following
Retinols
Benzolyl
Alpha hydroxy acids
If you have selected any of the above, when was it last used?
How does your skin heal?
Fast
Pigments
Slow
Have you had any surgery
Yes
No
If yes please give details below of what surgery and when you had surgery
Do you have any allegies/gluten intolorant
Yes
No
If yes please state below
What skin care products are you currently using and how frequently?
I confirm all of the above details are correct
Your Signature
Clear
Submit
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