Skin Assessment Form - Orchid Medical Aesthetics Sunderland

1. Name *

First

Last

2. Age *

3. Gender *

Female
Male
Rather not say

4. Which statement best describes your skin? (Choose one only) *

Very fair skin & burns instantly in the sun
Fair skin, burns easily & tans poorly
Medium white to olive skin, sometimes burns but usually tans
Olive/brown skin, rarely burns & always tans
Brown skin, never burns & always tans
Black skin, never burns & always tans

5. Tell us about your skin concerns (select all that apply to you) *

6. Describe your current daily skincare routine, including any skincare brands you are using. *

7. Any current professional skin treatments?

8. How much do you spend on skincare products? *

9. Do you have any allergies? *

10. Would you like to upload a photo?

Click or drag a file to this area to upload.

By uploading a close-up picture of your face your aesthetic doctor can examine your skin and offer more appropriate product recommendations. If you do not wish to upload a picture, please ignore this question.

11. Would you like us to contact you with treatment recommendations *

Telephone
Email

12. Provide a contact phone number *

13. Provide an email address (if you have one)

14. When is the best time to contact you? *

Morning
Afternoon
Evening

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