dermalogica by Hayley Lloyd Wilkins

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I have put together a short consultation card that will give me an insight to your skincare concerns.

Complete the Consultation card below by selecting one statement from each of the pull down menu's.
Analysis of your personal consulation card will be personally consulted by me.
I will then contact you via email my advice and a full skincare regime personalized to your individual needs.
On occasion it may be necessary for me to establish a time convenient to us both to discuss my findings and ask any further indepth questions to be able to give a more precise diagnosis.

consultation card

Please enter your full name:
Please enter your email address:
Contact telephone number:
1 Within the last year, have you been under any medical care?		Yes No
2 What skin care products are you currently using? (To select all that apply, use CTRL-click to select).
3 Do you ever experience the following conditions on your skin? (To select all that apply, use CTRL-click to select).
4 Do you ever experience skin breakouts? (To select all that apply, use CTRL-click to select).
5 Do you sunbathe or use tanning beds?		Yes No

6 Do you drink more than 4 caffeinated beverages each day?		Yes No
7 In the past month have you had chemical peels, dermabrasion or any resurfacing treatments?		Yes No
8 In the past 6 months have you used Retin A, Renova, Adapalene, Accutane or any other prescription skin products?		Yes No
9 Do you currently use any products containing any of the following ingredients? glycolic acid, lactic acid, scrubs, Vitamin A derivative (Retinol), hydroxy acids.		Yes No

10 Any other comments?

Want a more in depth consultation? Visit Hayley Lloyd Wilkins Dermalogica Skincare centre for a complete face mapping consultation. call or email Hayley to make an appointment.

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