Skincare Questionnaire – Skincare With Emily B

Personal Details

Full Name *

First

Last

Email *

Phone

Age Range *

Under 18
18-25
26-35
36-45
45+

If Under 18:

Parent/Guardian Full Name *

Parent Present *

A parent or guardian will be present during the consultation

Parent/Guardian Full Name *

Pronouns (Optional)

Are you booking the 12-week Bridal Preparation? *

Wedding Date

Skin Care History

Primary Skin Concerns (Select all that apply) *

Hyperpigmentation / Uneven tone
Acne / Breakouts
Sensitivity / Irritation
Dryness / dehydration
Oiliness / Congestion
Texture

Skin Type *

How long has this been a concern? *

Less than 3 months
3–6 months
6–12 months
Over 12 months

Have you experienced: *

Stinging or burning
Peeling or flaking
Breakouts after product use
Dark marks following irritation
None

Sun response

Always burns
Burns then tans
Tans easily
Rarely burns

List all products currently in use (AM and PM) *

Are you currently using any active treatments? (e.g. exfoliating acids, retinoids, pigment treatments)

List Active Treatments

Medications & Procedures

Are you currently taking or using anything that may affect your skin?

(e.g. isotretinoin/Accutane, tretinoin, antibiotics, hormonal treatments)

List of medications and procedures

Have you had any recent procedures?

(e.g. chemical peels, laser, microneedling, injectables)

List of recent procedures. *

Medical Considerations

Do you have any medical conditions that may affect your skin or treatment tolerance?

(e.g. eczema, psoriasis, rosacea, autoimmune conditions)

List medical conditions

Do you have tattoos in areas you are seeking advice for?

Specify where you have your tatoo(s)

Physiological Status

Pregnant
Breastfeeding
Planning
Neither

Additional Notes

Anything relevant to your skin

Picture

Please upload your pictures that show your face on all angle shown on the example here. Ensure the following:
- Natural lighting
- No makeup
- No filters

Front - Forward Facing *

Drag & Drop Files, Choose Files to Upload

Side - Facing Left *

Drag & Drop Files, Choose Files to Upload

Side - Facing Right *

Drag & Drop Files, Choose Files to Upload

Consent

I confirm the information provided is accurate

Consent (copy)

I understand this consultation provides professional skincare guidance based on the information provided

Consent (copy) (copy)

I understand this does not replace medical advice

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