Alpha-H Australia - Glycolic based Anti Ageing | Acne Treatment | Pigmentation | Sundamage

ONLINE SKIN CONSULTATION

For a customised programme specifically designed for your skin, please complete the form below and our fully qualified Beauty Therapist will recommend the right products for you!

Client Name:
Your Contact Email:
Your postal address:
Date of birth
Contact phone number:
ARE YOU PREGNANT OR BREASTFEEDING? Yes No Not Sure
SKIN ANALYSIS
Do you consider your skin to be sensitive? Yes No Not Sure
Are you allergic to any product or ingredient? If YES please list them.
Do you ever experience... Flaking skin Tightness Obvious dryness
Do you experience... Oily areas Blackheads Skin congestion
o you experience breakouts? If YES please describe which area on your face.
Your skin... Flushes easily Feels hot often Feels itchy or sting
What are some of your skin concerns?
Please list any medication or vitamins you are currently taking.
Have you ever taken Roaccutane? If YES please specify how long.	Have you ever taken medication specifically for your skin? If YES please specify the product.
Have you ever had the following procedures... Plastic Surgery Chemical Peel IPL Laser Microdermabrasion Skin Cancer Removal
Does your diet consist of... High Sugar High Fat Regular Alcohol Consumption Lots of fruit & veg
How much water do you consume per day on average? None 1 glass 2-3 glasses 1 litre 2 or more litres
Do you smoke? Yes No Occasionally
Do you suffer with constipation? Yes No Sometimes
Are you currently taking a contraceptive pill? Yes No
How often do you exercise? Never Once or twice a week 2-5 times per week Everyday
What results or improvements are you looking for in your skin?	Please list the products you are currently using. For example - Nivea night cream and soap.
Regarding your skin consultation - Please tick yes to either or both Do you consent to us contacting you... via email Yes via phone Yes

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Alpha-H wins Best Skin Refining Cream for our REJUVENATING CREAM

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