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.Your Age*Knowing 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*General HealthAre you pregnant or considering being so?YesNoWhen pregnant or breast feeding we recommend discussing the use of topical Vitamin A and pigmentation products with your doctor.Are 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:Are 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 themWhat 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.