Consultation Please provide the following information for a consultation: Full Name *FirstLastAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Telephone Number *Medical ReviewAre you currently taking any medication prescribed by a GP or other practitioner? *NoYesIf yes please provide further information:Are you currently taking any medication containing vitamin A? *NoYesIf yes please provide further information:Are you currently pregnant, planning pregnancy or breastfeeding? *NoYesIf yes please provide further information:Are you attending a GP or other practitioner for any other conditions? *NoYesIf yes please provide further information:Do you have any allergies or intolerances? *NoYesIf yes please provide further information:Do you have any allergies to ingredients in products? *NoYesIf yes please provide further information:DietHow would you describe your diet?How much water do you drink a day? (Litres)SkinHow would you describe your skin?Dry (tight, dull, flaky)Oily (breakouts, blackheads, shiny)Combination (dry cheeks, oily t-zone)Normal (balances and smooth)What are your main skin concerns? Please tick as many as appropriate:Fine LinesWrinklesEnlarged PoresPigmentationAcneRedness / Broken Veins RosaceaUneven Skin ToneScaringDo you have a history of the following:SmokingSunbedsSunburnHow sensitive is your skin?MildModerateVery SensitiveNot SensitiveAre you prone to or currently have any of the following?EczemaPsoriasisRosaceaHerpes SimplexDo you get any of the following?Comedones/blackheadsPustules/whiteheadsCystic AcneOccasional SpotsHormonal BreakoutsNever BreakoutHave you had any of the following?Fillers/botoxFacial surgical proceduresLaser treatment (i.e, IPL skin rejuvenation, hair removal)MicrobermabrisionWaxingChemical peelsMoles or sunspots removedOther skin treatments? Please specify:Facials? Please specify:What is your current skincare routine?CleanseTonerMoisturiserMask / SerumEyecreamSunblockWhat are your skin goals, what changes would you like to see?Please upload an image (up to 4) for a member of our team to analyse your skin.Image 2Image 3Image 4ConfirmationConfirm Information *I agree I have given the correct information above.Confirm Contact *I agree that Vale Laser Clinic can contact me to share product and treatment information. WebsiteSubmit For Consultation
