Beauty Concerns Registration and Consultation Form

Provide detailed information to help your skincare doctor prescribe the best treatment.

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Personal Information

Full Name * Email * Phone * Date of Birth * Gender *

Female Male

Note: Some questions may appear based on your gender selection.

Race / Ethnicity * Ancestral History * How did you hear about us?

Medical & Skin Conditions

Do you suffer from any of the following sicknesses? (Select all that apply) * Are you prone to any of the following? (Select all that apply) If other, specify Have you had any other form of cosmetic enhancement (surgical or non-surgical, including injectable fillers or Botox)?

Yes No

Do you have any other allergies?

Yes No

Know Your Skin Type

How would you describe your skin? * How often does your face breakout (spots, rashes, pimples etc)? *

Rarely Occasionally Constantly

In general, how would you describe your facial pore size? *

Invisible Small Medium Large and Obvious

What are your major skin care concerns? (Select all that apply) * If your skincare concerns are not listed above, please specify

Previous Treatments

3. Have you ever undergone any of the following treatments? (Select all that apply) Were you happy with the results? What do you hope to achieve with this consultation? *

Lifestyle & Preferences

Which statement best describes how you feel about skincare? How important is environmental UVA and UVB protection to you? *

Very Important Less Important

How does your skincare respond to sun? Do you use sunscreen?

Yes No

Have you done any of the following? (Select all that apply) How much sun exposure have you had in the past? *

Extreme Moderate

Do you smoke? *

Yes No

Do you drink alcohol? *

Daily Occasionally Only on special occasions I don't take alcohol at all

Are you on a restricted diet? *

Yes No

If yes, explain Do you exercise regularly? *

Yes No Sometimes

Are you taking oral contraceptive? *

Yes No

Are you pregnant or trying to get pregnant or breastfeeding? Do you have allergies? * Do you use the following? * If no, specify List any medication, supplement, vitamins, slimming pills etc. that you have been taking regularly. (If none, write none) * Run your finger down your cheek, how does it feel? *

Greasy and Oily Smooth and Supple Rough and Flaky Bumpy and Uneven

How does your skin feel after cleansing? (If you cleanse) *

Clean but oil appears within 20 minutes Nice and Clean A bit or very tight and dry

Do you have any other allergies to food stuff, drugs, chemicals, plants, flowers, milk, egg, fish, shellfish, wheat, etc? Does your skin have dry patches?

Yes No

Is your skin extremely dry all over?

Yes No

What hair products are you currently using? What do you use to wash your face? * What type of moisturizer do you use? (Specify or type none) * Have you used glycolic? If yes, specify the percentage or type no * What time of the day do you first notice oil? (If you don't have oil at all, specify) * Where do you feel oily? * How do you usually prefer to wash/bath? * What are your main body skincare treatment concerns? *

Exfoliation Bleaching History

Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatment? *

Yes No

In the last month? *

Yes No

Do you use an acne medication? *

Yes No

In the last 6 months? *

Yes No

If yes, specify the drugs Are you currently using any product that contains the following ingredients? (Select all that apply, ignore if no) Have you ever used any of the following? (Select all that apply) If selected any, product name specify Do you experience an allergic reaction to bleach or fade cream such as swelling, itching or fine bumps, rash? *

Yes No

Are you using any topical medication that causes you to peel? *

Yes No

If yes, product name

Male Guests Only

Preferences

Which of these statements best describes how you think about price or value of beauty care products? *

I buy the lowest priced beauty care products from among limited set of brands I trust I always buy the lowest priced beauty products I occasionally pay a little extra for beauty care products I like or think are a little better I buy beauty care I want and I don't bother about the price so long as it works

What type of facial cleanser do you prefer? * For the right moisturizer, select the statement that best describes your skin needs (Select all that apply) *

I want to help prevent lines and wrinkles My skin doesn't seem as firm My skin is beginning to sag My skin often feels dry and dehydrated I have a problem with oiliness and clogged pores My skin is sensitive and gets red, spotty and irritated

For the right anti-aging specialist treatment, select the statement that best describes an additional concern of yours (Select all that apply) *

Dull/flaky with uneven texture Erase clear off discoloration, age spots, sunspots, etc Prevent/repair the signs of premature aging Erase medium to deep lines/wrinkles with the latest methods and trends in the industry Resolve aging dilemmas

For the eye care formula, select your main eye area concern (Select all that apply) * What results are you hoping to achieve with the use of your products and our treatments? *

Uploads

Upload clear face image * Upload a clear signature of yourself in a white paper with your name and date written on it *

Declaration

Please read the following statement and sign if you are willing to continue with Beauty Concerns 'The Skincare Clinic'.

The information I have given is to the best of my knowledge correct. I have not withheld any medical or surgical condition. Note: I understand I will require multiple treatments depending on my response to the treatment to achieve optimal results. Clinical results may vary in different skin types, hair colors, and ethnic backgrounds including hormonal changes due to age or medication. I understand that I have been advised to avoid sunlight exposure. I understand that there can be short-term side effects and I have been made aware of this. I understand that results can only be achieved if the skincare routine and products recommended are done and used by me.

Confidentiality

User Privacy protection

NOTE!!! Please take a little extra time to read our privacy and confidentiality clause.

Privacy and Security: Our goal at Beauty-Concerns is to provide a unique, safe, secure and pleasant consulting and shopping experience for all our Clients.

Beauty-Concerns is committed to protecting your privacy and security as a client and individual.

We only collect information that you give us and WE DO NOT SELL OR RENT YOUR PERSONAL INFORMATION TO ANY INDIVIDUAL OR ORGANISATION.

CONFIDENTIALITY: The information contained in this document is strictly confidential. It is intended for use by Beauty-Concerns in determining the best skin care routine for you and will not be used by any other person or organization.

THANK YOU FOR YOUR TIME AND CO-OPERATION, SEE YOU AT YOUR APPOINTMENT.

I understand all the information that has been told to me and I have read all the above information with regards to contraindications with the treatment I have undertaken whilst visiting Beauty Concerns 'The Skincare Clinic'.

Yes

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Beauty Concerns Registration and Consultation Form

Personal Information

Medical & Skin Conditions

Know Your Skin Type

Previous Treatments

Lifestyle & Preferences

Exfoliation Bleaching History

Male Guests Only

Preferences

Uploads

Declaration

Confidentiality