01786 816817 | info@beautyhealthaesthetics.co.uk | Mon – Sun 09:00 – 21:00

Home
About Us
- BHA Clinic Gallery
Prices
Treatments
Shop
Blog
Book Online
Contact Us

Skin Consultation

Name *

First

Last

Email *

Date of Birth *

Phone *

Skin Type *

Skin Sensitivity *

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

Drag & Drop Files, Choose Files to Upload

Beauty Health Aesthetics

149 Bannockburn Road
Stirling, FK7 0EP

01786 816817
info@beautyhealthaesthetics.co.uk

Opening Hours

09:00AM – 21:00PM
Monday – Sunday

Get Social

Scroll to Top