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Name

Phone

How old are you?

Gender

Male

Female

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What is your main skin concern today?

Select Acne / Breakouts Pigmentation / Dark spots Fine lines / Wrinkles Dullness / Uneven tone Sensitive / Reactive skin Other

What is your skin type?

Select Normal Oily Dyr Combination Sensitive / Easily irritated

How often do you experience oiliness/shine during the day?

Select Rarely Occasionally Often Constantly

How often does your skin feel tight, rough, or flaky?

Select Never Occasionally Often Constantly

Do you have redness, flushing, or visible broken capillaries?

No

Yes – rarely

Yes – moderately

Yes – frequently

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How would you describe your pores?

Select Not visible / Fine Visible in T-zone Visible across much of face Large / Deeply open

Do you have scars, marks, or texture irregularities?

Select None Mild Moderate Severe

Sun exposure & SPF habits:

Select Minimal sun exposure, always use SPF Moderate sun exposure, sometimes use SPF High sun exposure, rarely use SPF Very high exposure, no SPF

Any medical conditions or medications affecting skin?

No

Yes

Any skin/aesthetic treatments in last 12 months?

Yes

No

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Current skincare routine:

No

Yes – basic cleanser & moisturiser only

Yes – active skincare (acids/retinoids/etc.)

Hydration & diet quality:

Good

Ok

Poor

Smoking or alcohol consumption

No

Occasionally

Yes – regularly

Stress & sleep quality

Select Low stress, good sleep Moderate stress, fair sleep High stress, poor sleep

Any allergies or sensitivities?

No

Yes

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Pregnant or breastfeeding

No

Yes

Prefer not to say

Goal timeframe for results:

Select Short-term (4–6 weeks) Medium (3–6 months) Long-term (6+ months)

Preferred treatment intensity:

Select Non-invasive / gentle Moderate (peels, microneedling) Aggressive / advanced

Commitment to home-care routine:

Select Very committed Somewhat committed Not sure / need discussion

Any other information we should know?

Book Appointment

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