01786 816817
info@beautyhealthaesthetics.co.uk
Mon - Sun 09:00 - 21:00
Home
Phone-alt
Map-marked-alt
Facebook-f
Instagram
Shopping-basket
About Us
Treatments
Shop
About Us
Treatments
Shop
Home
About Us
BHA Clinic Gallery
Prices
Treatments
FACE
Wrinkle Reducing Injections
Dermal Fillers
Lip Enhancements
Fibroblast
ThermaVein
Clinical Peels
DERMAL ROLLER
Mesotherapy
Collagen stimulating therapy
Environ Ionzyme DF11 Advanced Facial
L.E.D Light Therapy
Carboxytherapy
WOW Infusion / Facial
Body
Fibroblast
Hair Restoration
ThermaVein
DNA Testing
Microsclerotherapy
Under arm treatment for sweating
Aqualyx Fat Dissolving Injections
Carboxytherapy
Mesotherapy
Clinical Peels
Fibroblast
DERMAL ROLLER
CM-Slim
FV Weight Loss Program
Personal fitness trainer program
Beauty Services
SKIN
Obagi medical skincare programs
Image skincare
Environ skincare
Beaute Pacifique skincare
IPL skin rejuvenation
Micro needling for scars
Clinical Peels
Environ Ionzyme DF11 Advanced Facial
BioRePeel Cl3 Facial
WELLNESS
ANTI-HAYFEVER TREATMENTS
BHRT
BHRT Consultation
WELLNESS INFUSION
VITAMIN B12 INJECTIONS
CLINIC SPECIALS
Book Online
Shop
Blog
Contact Us
My cart
No products in the basket.
Skin Consultation
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Date of Birth
*
Phone
*
Skin Type
*
Normal
Dry
Oily
Oily T-Zone
Skin Sensitivity
*
Normal
Sensitive
Very Sensitive
Do you have any allergies / intolerances (e.g Aspirin)?
*
Yes
No
If 'yes' please specify
Have you ever had any facial surgical procedures?
*
Yes
No
If 'yes' please specify
Have you ever had laser hair removal?
*
Yes
No
If 'yes' please specify
Have you ever had any laser treatments?
*
Yes
No
If 'yes' please specify
Have you ever had any botox or dermal fillers?
*
Yes
No
If 'yes' please specify
Have you ever had any microdermabrasion?
*
Yes
No
If 'yes' please specify
Have you ever had any waxing?
*
Yes
No
If 'yes' please specify
Have you ever had any chemical peels?
*
Yes
No
If 'yes' please specify
Have you ever had any moles or sun spots removed?
*
Yes
No
If 'yes' please specify
Have you ever had any other skin care treatments?
*
Yes
No
If 'yes' please specify
Are you Pregnant, trying or breastfeeding?
*
Yes
No
If 'yes' please specify
Are you diabetic?
*
Yes
No
If 'yes' please specify
Do you have porphyria?
*
Yes
No
If 'yes' please specify
Do you have epilepsy?
*
Yes
No
If 'yes' please specify
Do you have any menopausal or puberty symptoms?
*
Yes
No
If 'yes' please specify
Do you have any holiday and sun exposure history?
*
Yes
No
If 'yes' please specify
Do you have a pacemaker or cardiac irregularities?
*
Yes
No
If 'yes' please specify
Do you have Multiple Sclerosis?
*
Yes
No
If 'yes' please specify
Do you have any Facial Metal Implants or Excess Fillings?
*
Yes
No
If 'yes' please specify
Are you a smoker?
*
Yes
No
If 'yes' please specify
Do you have any Skin Conditions (e.g eczema psoriasis)
*
Yes
No
If 'yes' please specify
Do you have, or have you ever suffered from rosacea?
*
Yes
No
If 'yes' please specify
Please list any recent illnesses
*
How would you describe your diet?
*
How much water do you drink a day?
*
How much alcohol do you consume a week?
*
Are you taking any topical or oral Cortisone / prescribed skin treatment?
*
Yes
No
If 'yes' please specify
Are you taking any Topical or oral Antibiotics?
*
Yes
No
If 'yes' please specify
Are you on HRT?
*
Yes
No
If 'yes' please specify
Are you on the Contraceptive Pill?
*
Yes
No
If 'yes' please specify
Are you on any other Medication?
*
Yes
No
If 'yes' please specify
Are you taking any Vitamin Supplements?
*
Yes
No
If 'yes' please specify
What skincare products are you currently using?
*
What make-up brand are you currently using? Which products?
*
What skin changes would you like to see in your skin?
*
Please select your skin type:
*
Pale white skin, blue/green eyes, blond/red hair - Always burns, does not tan
Fair skin, blue eyes - Burns easily, tans poorly
Darker white skin - Tans after initial burn
Light brown skin - Burns minimally, tans easily
Brown skin - Rarely burns, tans darkly easily
Dark brown or black skin - Never burns, always tans darkly
Upload an image of your current skin if required
Click or drag a file to this area to upload.
Submit
