Online Skin Consultation in Blackrock

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Do you have any medical conditions? *

Please tick the appropriate box below

Yes*

No

Are you on any medication? *

Yes*

No

Do you have any allergies? *

Yes*

No

Are you pregnant or breastfeeding? *

Yes

No

Past Roaccutavne treatment? *

Yes

No

Are you taking or using Reinol A, Gylycolic Acid, Salicylic acid?

Yes*

No

What are your main skin concerns? *

Fine Lines

Wrinkles

Enlarged Pores

Pigmentation

Acne

Redness Rosacea

Scarring

Uneven Skin Tone

Do you have any of these skin conditions? *

Dry (Eg Tight, Dull & Flakey)

Oily (Eg Breakouts, Blackheads & Shiney)

Combination (Eg Dry Cheeks, Oily T-Zone)

Normal (Eg Balanced & Smooth)

Do you have a history of the following? *

Smoking

Sunbeds

How sensitive would your skin be? *

Mild

Moderate

Very Sensitive

Not Sensitive

Are your prone to or currently have the following? *

Eczema

Psoriasis

Rosacea

Cold sores

None

Do you get any of the following? *

Comedones/Blackheads

Pustules/White Heads

Cystic Acne

Occasional Spots

Hormonal Breakouts

Never Breakout

What is your current skincare routine? *

Cleanse

Toner

Moisturiser

Exfoliant SPF

Mask

Eye Cream

I agree I have given the correct information above. Yes

Yes, I agree I have given the correct information above.

No, I do not agree I have given the correct information above.

Are you attending any GP or other practitioner for any other conditions?

Yes

No

How would you like your consultation done? *

Phone

Zoom

Email

Skin Photos *

Please email blackrock@invogue.ie the following images of cleansed skin areas for one of our skin specialists to analyse your skin and your skincare recommendations. Front, Right Side, Left Side

Yes

No