Online Consultation Form - Liebe Wellness

Name*

First

Last

Phone*

Date of Birth*

day

/

month

/

year

Gender*

Female

Male

Prefer not to answer

Email*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Please check options below*

Pregnant?

Breasfeeding?

Do you Smoke?

NIL

Do you have any allergies? If yes, please describe below*

Yes

No

Allergies:

Have you had a peel or microdermabrasion? If yes, please state when below*

Yes

No

DATE: Peel or Microdermabrasion

Do you have botox or any form of injectables? If "Yes", please describe below*

Yes

No

Injectables:

Have you had previous facial surgery? If "Yes", please describe below*

Yes

No

Facial Surgery:

Other treatments we should be aware of? If "Yes", please describe below*

Yes

No

Other treatments:

What are your top 3 main skin concerns? *

Do you have any skin conditions? eg: Eczema/Psoriasis - If "Yes", please describe below*

Yes

No

Skin Conditions:

Current skincare routine (AM+PM)*

Brand of each product you are currently using?*

Have you used Roaccutane or Acne Medication?*

Yes

No

BRAND

TIMEFRAME

LAST USED

How much water do you consume daily?*

Do you have a healthy diet, or could this be improved?*

Excellent

Fairly Good

Somewhat Good

Could be better

Do you exercise regularly?*

Yes

No

Sometimes

Please Upload 3 x photo’s concentrating on problematic area of concern.

Upload a File

What are your expectations from this consultation? *

Product Recommendation

Treatment Plan

Other - please advise below

Other ...

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Online Skin Consultation

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