Consultation | Skinfinity Beauty and Skin Clinic

Book a consultation with Caroline

If you can complete the AlumierMD Patient Questionnaire on the link below, Caroline will be in touch to confirm a suitable date.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone / Mobile *

Date of Birth

Email *

Please enter your email, so we can follow up with you.

What is the main reason for your visit today?

Which of these statements is most applicable to you?

I would like to look better for my age
I would like to change something that has been bothering
I would like to look more attractive

Have you had an aesthetic consultation or treatment before?

How often do you think about having an aesthetic treatment?

Most days
Weekly
Monthly

When I think about my appearance, I feel I look... (Please tick #3)

Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive

On a scale of 1 – 10 (1 being desperately unhappy and 10 being extremely happy) how satisfied are you with your overall appearance?

Selected Value: 0

On a scale of 1 – 10 (1 being desperately unhappy and 10 being extremely happy) how satisfied are you with your skin?

Selected Value: 0

After treatment I would like to feel? (Please tick #3)

Fresher
Happier
Brighter
More awake
More youthful
Slimmer
More attractive
More luminous
More confident

List your desired outcomes in order of priority

What are your main skin concerns?

When did you first notice your concern?

Do you notice your skin concern gets worse at any time of the day / month / year?

Do you exfoliate in the week?

What is your current skincare routine?

Morning Routine
Evening Routine

Do you wear sunscreen?

How is your current skincare helping your skin?

Which of these in-clinic treatments interest you?

Skincare
Chemical peels
IPL
Microdermabrasion
Facials
Dermaplaning
Pigment reduction – cryotherapy
Skin tightening
Skin injectables
Micro-needling
Mesotherapy
Laser
Muscle relaxant injections
Facial fillers
Facial threads
Nose augmentation
Brow correction
Eyelid correction
Fat reduction – chin
Ear correction
Capillary removal
Laser hair removal
Thread vein removal
Hair replacement
Labiaplasty
Fat reduction
Breast enlargement
Tummy tuck
Arm lift
Buttock augmentation

How did you hear about us?

My doctor
Adverts
Recommendation
Search engine
Social media

Preferred contact details:

Phone
Email
Post

Consent *

I consent to this data being collected and in the event of an adverse reaction, I consent to the clinic passing this information to AlumierMD for further advice

Signature *

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