First Name *

Last Name *

Email *

Phone *

Address

City

Postcode

Gender

Date of Birth *

Preferred Method of Communication

Have you had any cosmetic enhancements before?

Dermabrasion
Dermapen/ Skin Needling
Fractional Laser
Photorejuvenation (VPL or IPL)
Hair Removal (VPL, IPL, Electrolysis)
Professional Chemical Peels
Permanent/Tattooed Makeup
Dermal Filler eg. Juvederm® or Restylane®
Wrinkle relaxing treatments eg. Botox® or Dysport®

If you ticked any of the options above can you please detail for us when this took place and how did you find the result?

Have you had any significant illnesses or operations?

Have you ever had local anesthetic?

Do you have any dental problems or planned dental work?

Are you currently being treated for any medical conditions?

Are you taking any prescription medication, including contraception?

Are you regularly taking anti-inflammatories?

Have you ever taken Roaccutane/Isotane?

Have you ever used Retin A, Retinol?

Are you taking any supplements, vitamins?

Do you have any known allergies or sensitivities?

Do you have any active skin diseases, infections or cancerous lesions?

Do you have a diminished/exaggerated perception of skin temperature?

Have you had a baby in the past 12 months?

Are you breastfeeding currently?

Are you pregnant or planning to be in the next 3 months?

If you ticked any of the options above can you please detail this for us or let us know of any medical condition you have that is not included on this list?

Father's Ethnicity

Mother's Ethnicity

Is there a direct family history of melanoma?

Your eye colour?

Light blue
Blue, grey, green
Blue
Dark brown
Brown to black

Your natural hair colour?

Sandy Red
Blonde
Chestnut, Dark Blonde
Dark Brown
Black

Your skin tone?

Reddish
Very pale
Pale to Beige
Light brown
Dark brown

Do you have many freckles?

Many
Several
Few
Hardly any
None

What happens if you stay in the sun for a bit too long without protection?

Painful redness, blistering, peeling
Blistering followed by peeling
Burns sometimes, and peeling
Rarely burn
Never burn

To what degree do you tan after sun exposure?

Hardly, or not at all
Light colour tan
Reasonable tan
I tan very easily
I turn quite dark brown quickly

Do you tan quickly/several hours after sun exposure?

Never
Seldom
Sometimes
Often
Always

How does your face respond to sun exposure?

Very sensitive
Sensitive
Normal
Very Resistant
Never had a problem

When did you last expose your face to the sun, sun beds or self tanning lotion?

More than 3 months ago
2-3 months ago
1-2 months ago
Less than 1 month ago
Less than 2 weeks ago

Do you expose the area you want to treat to the sun?

Never
Hardly Ever
Sometimes
Often
Always

Thanks for getting in touch!

Thank you for taking the time to fill out this form! We look forward to meeting you and helping you achieve your skincare goals.

Thanks for getting in touch!

Thank you for taking the time to fill out this form! We look forward to meeting you and helping you achieve your skincare goals.

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Shop all SKIN products

Dp Dermaceuticals