Your InformationName* First Last Email* Are you based in Australia?*YesNoSorry, the online skin consultation service is currently only offered to customers based in Australia.Please Check one of the boxes below*I would like to receive News, Promotions and Information via email to help me on my skin care journey. I understand that i am able to unsubscribe at any time in the future by clicking on the Unsubscribe button at the end of each Newsletter. Yes NoYour AgeKnowing your age really helps me to understand your skin.Address (City, State, Postcode)The climate and pollution levels that you live in affect your skinDescribe your skin concern*Briefly describe any changes you have noticed in your skin, especially as a teen, under stress, when pregnant or when travelling.General HealthAre you pregnant or considering being so?YesNoAre you breastfeeding?YesNoWhen pregnant or breast feeding we recommend discussing the use of topical Vitamin A and pigmentation products with your doctor.Do you suffer from a chronic illness?YesNoIf you do have a chronic illness, please describe:Are you currently on any medications? Including any vitamins/ supplements?YesNoPlease list any medications/vitamin supplements here:How much do you drink of the following per day?WaterTeaHerbal TeaCoffeeAlcoholDo you smoke?YesNoAre you vegetarian or vegan?VegetarianVeganNeitherDo you eat healthily?YesCould be improvedPlease provide any details you feel may be relevantHow many times a week do you eat the following?Red meatFishLeafy greensDo you exercise regularly?YesNoPlease describe how often & the type of exercise:How much time per day do you spend outside?Skin HistoryHow often do you have a peel, microdermabrasion or chemical facial?NeverNot oftenMonthly3-6 monthly6-12 monthlyAre you currently using or have used previously topical retinols or Ro-Accutane?Yes - currently usingYes - used in the pastNoPlease advise when was the last time you used themDo you have any form of injectables e.g. anti-wrinkle injections?YesNoIf yes, please include what you have, how often and when was your last treatment:Have you ever used a product which has caused a reaction you haven’t liked? If so, please describe even if you can’t remember the product – maybe the type of place you purchased it from.What is your current skin care routine? Include the brands please.MorningEveningDo you use sunless tanning products?YesNoWhich sunless tanning products do you use?Do you use makeup?YesNoWhich makeup products do you use?Please upload 3 x photo’s concentrating on the areas of concern to you. Drop files here or Accepted file types: jpg, gif, png, pdf.Depending on the speed of your internet connection, photos may take some time to upload. You may want to resize large photos to a smaller size first. WE endeavour to reply to you within 48 hours however please understand if we need to wait until the weekend. We consider each submission as though you are sitting opposite us in our consulting room.Do you want to recommend this questionaire to a friend?We can send your friend an email on your behalf suggesting they may like to have a look at this questionaire. If they become a customer of the Skin Care Clinic in the next 30 days, we will also reward you with 300 rewards points to redeem on a future purchase!YesNoYour friends email address This iframe contains the logic required to handle Ajax powered Gravity Forms.