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Name:
Surname:
Cellphone Number:
Email:
Are you pregnant/trying to fall pregnant YesNo
What are your primary skin concerns that you wish to treat?: AcneAged Skin (fine lines and wrinkles)BlackheadsDehydrationDry skinOily skinDull skinEnlarged poresDark circlesPigmentationSensitive skinSun damageRosaceaStretch marksScarring
Other Concerns:
What is your current skincare routine like? (Include products)
Are you currently taking (or have taken in the last 3 months) any of the following medications: Isotretinoin (Roaccutane/Accutane/Isotane)Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)Contraceptive pillNone
Do you spend a lot of time outdoors? If yes, specify how often.
Do you have any known allergies? (if yes, please state in detail)
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