Skin Care Consultation
Full Name
Date Of Birth
Address
Mobile Number
Email
GP Surgery
I agree for the Clinic to consult my GP for further information about my illness if required
Yes
No
Allergies
Yes
No
Asthma
Yes
No
Autoimmune Disorder
Yes
No
Bleeding Disorder
Yes
No
Blood Clots
Yes
No
Blood Thinning Medications
Yes
No
Cancer/History of Cancer
Yes
No
Depression/Anxiety
Yes
No
Keloid Or Hypertrophic Scars
Yes
No
PCOS
Yes
No
Pregnant or Breastfeeding
Yes
No
Cold Sores
Yes
No
Vitiligo
Yes
No
Eczema
Yes
No
Psoriasis
Yes
No
Dermatitis
Yes
No
Roaccutane
Yes
No
Retin A
Yes
No
Tetracycline
Yes
No
WHAT IS YOUR CURRENT SKIN ROUTINE?
How would you describe your skin ?
Dry
Normal
Oily
Is your skin sensitive ?
When skin is sensitive, it becomes easily irritated when exposed to topical ingredients or environmental stressors, causing symptoms such as redness, stinging, dry patches or itching skin. Sensitive skin can more accurately be referred to as weak skin. When sensitivity is present, ZO® recommends specifically designed products to strengthen the skin, waking the cells up to restore normal hydration and skin renewal. Once the skin becomes strengthened, more aggressive programs for specific treatment and repair can then be gradually introduced.
Yes
No
Do you prefer a mild or a more aggresive treatment approach ?
If aggressive, please note that initial reactions such as redness, peeling, dryness and irritation are normal and signs of good repair. Reactions can be controlled by adjusting the program strength by decreasing the frequency of application or the amount of product applied.
Mild
Aggressive
What are your primary skin concerns ?
Pick up to 2.
Fine Lines + Wrinkles
Deep Lines + Wrinkles
Loss of Firmness
Skin Sagging
Rough Skin Texture
Skin Dullness
Uneven Skin Tone
Dark Spots/Patches
Clogged Pores + Blemishes
Acne
Rosacea
Redness + Sensitivity
What are your primary skincare goals?
Pick up to 2.
Prevent Signs of Aging
Reverse Signs of Aging
More Even-Toned Skin
Clearer + Smoother skin
Minimize Skin Redness
Restore Hydration
Sunscreen is recommended with every regimen. Which do you prefer ?
POWDER: for flawless finish
TINTED: for even complexion
SHEER: for superior function
Which of the ZO Skin Health products do you require?
POTENTIAL REACTIONS
When first using your new skincare regime, your skin may feel dry, tight, flush, breakout or sting, these are all normal side effects due to an impaired skin barrier function. When the barrier function is compromised it can become sensitised resulting in blemishes, inflammation, dehydration, fine lines etc. and ultimately ageing the skin. The skincare is designed to rebuild and strengthen the skins barrier function, but during this period the reactions can last from 2-8 weeks.<br><br>To achieve best results safely, we strongly advise you to strictly follow your prescribed skin regime in order to achieve your desired results.<br><br>By completing this form and purchasing ZO skincare through PUREHEALTH Aesthetics:<br><br>- You have given us accurate medical information for us to prescribe the correct skincare for you<br>- You understand that your skin may react when you begin your skincare routine<br>- You will follow your skincare routine as prescribed in order to achieve desired results<br>- You understand your routine has been put together for you an as individual so may differ from others<br>- We do not offer refunds for ZO Skin Health products. Although these are evidence based products we cannot guarantee individual results.
USE OF SPF
To achieve best results safely, we strongly advise you to strictly follow your prescribed skin regime which includes using a ZO SPF.<br><br>By completing this form and purchasing ZO skincare through PUREHEALTH Aesthetics:<br><br>- You understand that ZO Skin Health products have active ingredients in them and must therefore be prescribed to you by the clinic<br>- You understand in order to ensure the best results you MUST use the prescribed ZO SPF.<br>- You understand that the failure to use the SPF can result in poor results, pigmentation, sensitivity, irritation, redness and breakouts.
DATA PROTECTION
As part of its records, PureHealth Aesthetics will maintain your contact details, information about your health and other personal data which you provide on this form or subsequently. PureHealth Aesthetics will keep such data secure and will process it in accordance with data protection legislation. PureHealth Aesthetics may use such data for its own marketing purposes but will not disclose it to any third parties other than as required by law. You have a right to ask for a copy of the data held by PureHealth Aesthetics and to correct any inaccuracies (May incur a charge).
Terms of Service
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