FACIAL CARE CONSULTATION FORM

To enable us to provide your bespoke remedy, please provide as much information as you can using the form below:

Contact Details

First name(s) *

Surname

Address

Postcode

Telephone *

Mobile

Email Address *

Sex

Male Female

Date of Birth

* Please tick answers to following questions in appropriate boxes

Pregnant

Yes No

Trying to conceive

Yes No

Any allergies

Yes No

* Please be aware that our base lotion contains jojoba, almond and macadamia nut oil

Pollen allergies

Grass Flowers Tree Spore

Food allergies

Cheese Wheat Gluten Nuts Shellfish

Other Allergies

Please describe your allergy symptoms

Asthma Skin rash Swelling Anaphylactic shock

Other Symptoms

Skin Type

Sensitive Dry Mature Combination Oily

Acne Acne Rosacea Sun Damaged Scarred

Please provide details of prescribed lotions for the above conditions

Site By Reason