SKIN ANALYSIS FORM

Professional Analysis and Treatments for Hair Loss, Scalp Disorders and Skin problems.

Please submit online. If you prefer, you can printout, email, fax or post this form to us.

All skin preparations are prescribed on an individual basis Please incl. £12.50 Sterling Fee. When Skin analysis complete, a full report and rec. on treatments and prices will be sent.

Please pay analysis fee of £12.50 in the product page, or send to the address below. Alternatively, the analysis form can be e-mailed and fee paid by credit card.

If you require any further information about this process please e-mail or telephone us at 01475 724629.

A full analytical report will be e-mailed or sent to you detailing recommended treatments.
Should you decide to proceed with the treatments you may order via e-mail or by post, including your cheque.

 

Instructions: Complete form below or print off paper version to post via mail.

1. Sex

2. Date of Birth

3. Name

4. Address

5. Postcode

6. Telephone (Incl. Area Code)

7. Ethnic Group Other

8. Occupation

9. Outdoor Activities

10. Swimming

11. Other Sports and how often

12. Sun Bathing/Sunbed

13. Special Diet Details

14. Daily Liquid Intake

15. General Health

16. Stress Level

17. Illness in the last 12 months

18. Recent Surgical Intervention

19. Prescribed Medicines

20. Family skin history

Genetic History

21. Fathers Side

22. Mothers Side

23. Additional Information & Comments

24. Present Skin Care Products Normally Used

25. Cleansing

26. Day Cream

27. Night Cream

28. Other

Visual Observations

29. Skin Condition

30. Complexion

31. Where

32. Acne

IF YES for above, please give further information in the additional info section e.g. is acne pustular, weeping, blackheads, what areas are affected, chin, forehead, around cheeks, what treatment have you been using and for how long etc. Please give as much information as possible.

Manual Observations

33. Elasticity - Face

34. Elasticity - Neck

Pinch and lift the skin between the forefinger and thumb, see how long the skin takes to return to normal.

35. Skin Thickness

Lift the skin and feel the thickness with the fingers.

Supplementary Information

36. Body Skin condition

37. Cellulite

38. Water Retention

39. Make up stable?

The Sun

40. Reactions to sunbathing

41. Tan Easily

42. Email Address

Thank You. Please Click the following button to send the form.

 

Ninian Smith 46 Inverkip Street Greenock PA15 1YT Scotland UK Fax: 01475 729 255
E-mail: Ninian Smith
You may book a personal appointment for consultation and analysis.