Consultation Forms

YOUR HEALTH

1. Within the last year, have you had any health problems that have affected or could affected or could affect your skin?*

Yes
No

If yes, please specify:

2. List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin etc, that you take regularly.

3. Do you wear contact lenses?*

Yes
No

4. Do you have metal implants, a pacemaker or body piercings?*

Yes
No

5. Do you have any allergies?*

Yes
No

If yes, please specify:

6. Do you have sinus problems?*

Yes
No

7. Have you ever experienced claustrophobia?*

Yes
No

YOUR SKIN

8. What are your specific concerns/challenges with your skin?

9. What skin care products are you currently using?*

Soap
Cleanser
Toner
Moisturiser
Masque
Exfoliant
Eye products
Other

Explain which brands of skincare you are currently using

10. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?*

Yes
No

11. Have you:

Please tick if the answer is YES

Been waxed within the last 72 hours?
Shaved within the last 24 hours?

12. Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?*

Yes
No

13. Are you currently using any products that contain the following ingredients?

If yes please tick the below:

Glycolic Acid
Lactic Acid
Any exfoliating scrubs
Other Hydroxy Acids
Vitamin A derivatives (i.e. Retinol)

14. Please specify if any of the following apply to you:

Pregnant
Trying to become pregnant
Lactating
Menstruating
Pre-menstrual

15. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc.*

Yes
No

16. Do you have active cold sores?*

Yes
No

17. Have you received Botox or other injectable procedures within the past week?*

Yes
No

18. Do you sunbathe or use tanning beds?*

Yes
No

19. Do you experience redness, itching, or stinging on your skin?*

Yes
No

Contact Details

Name*

First Last

Address*

Street Address Address Line 2 City County Post Code

Email*

Phone*

Birthday

How did you hear about Alchemy?

Submit your consultation form

By clicking submit you are confirming (to the best of your knowledge) that the answers you have given are correct and that you have not withheld any information that may be relevant to your treatment. DATA Alchemy take privacy seriously. As the data controller of the personal data that you have provided on this form, we will use your personal data for the purpose of carrying out your consultation and keeping a record of your treatments. Please refer to our full privacy policy on Alchemy's website for more information about your rights and how we use your personal data. If you have any questions please email info@thealchemy.co.uk.

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YOUR HEALTH

YOUR SKIN

Contact Details

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