BOOK A FREE SKIN CONSULT BOOK A FREE SKIN CONSULT NEW PATIENT Returning Patient Step 1 of 4 25% Patient Type(Required) I am a new patient I am a returning patient Full Name(Required) First Last Your Email Address(Required) Your Phone(Required)How did you hear about us? Word of mouth Google search Instagram/Facebook Social media group If a phone call is required, what is the best time to call?(Required) 8am-10am 10am-12pm 12pm-3pm 3pm-5pm Tell Us More About You:Date Of Birth(Required) DD slash MM slash YYYY Please tell us your occupationPostal Address for delivery of products(Required) Street Address Suburb State Postcode Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments Tell us about your skin journey so far:Have you had a skin cancer checkup in the past 12 months?(Required) Yes No Have you ever been prescribed treatment for: Acne Allergic Skin Dermatitis/Perioral Dermatitis Pigmentation/Melasma Psoriasis Rosacea Skin Allergy Other Please ListDo you use the following in your daily skincare routine? Cleanser Toner Moisturiser Serums Sunscreen Please provide details of productsHave you ever had a reaction to a skincare product? If so, please specify and describe reaction:Current Medications and/or Medical ConditionsHave you ever had an allergic reaction to a medication? If so, please specify and describe reaction:Have you received any of the following treatments in the past 6 months? Chemical Peels Cosmetic Tattoo Facials Laser IPL Microdermabrasion Microneedling Other Please List Tell Us About Your Skin GoalsWhat improvements would you like to see?I am open to trying: Prescription skincare AHA/BHA creams Estriol face creams A new wash and moisturiser A new suncreeen Anything (Try me!) Please chose as many asI am also open to trying the following brands: Biopelle Dermaceutic La Roche Posay - Please upload ONE photo of your skincare in order of application. (ie. cleanser, actives, moisturiser, SPF) - Please upload THREE pictures of your face in natural light no makeup (one front profile, one left profile and one right profile)File Drop files here or Select files Max. file size: 10 MB. CAPTCHAConsent(Required) Enjoy your free skin consultation. Please carefully read the privacy information below.I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of advice or treatment. I consent to My Skin Pharmacy using the information to provide the best possible outcome and I confirm that I have read and fully understand this consent form. Our doctors will only prescribe treatment if remote prescription treatment is safe and appropriate for you. A treatment is not guaranteed. In accordance with the privacy act (1988) all information collected is treated as "sensitive information". To protect your privacy, My Skin Pharmacy operates in accordance with the act. Australian Federal Privacy Laws require the pharmacy to receive your consent to collect your personal medical information.Your medical information will be used exclusively for the purpose of providing health care and treatment.Skincare Consult Price: Total Step 1 of 3 33% Full Name(Required) First Last Contact Number(Required)Email(Required) Postal Address for delivery of products(Only required if details have changed since your last consultation.) Street Address Suburb State Postcode If a phone call is required, what is the best time to call?(Required) 8am-10am 10am-12pm 12pm-3pm 3pm-5pm Are you happy with your current routine?Are there any new products or ingredients you would like to try?Do you have any other comments or questions for our pharmacist?Has your medical condition(s) or medication(s) changed since your last consult? Please provide details below.Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments If you would like to give us new updated photos of your skin, please do so.- Please upload THREE pictures of your face in natural light no makeup (one front profile, one left profile and one right profile)File Drop files here or Select files Max. file size: 10 MB. CAPTCHAConsent(Required) Enjoy your free skin consultation. Please carefully read the privacy information below.I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of advice or treatment. I consent to My Skin Pharmacy using the information to provide the best possible outcome and I confirm that I have read and fully understand this consent form. Our doctors will only prescribe treatment if remote prescription treatment is safe and appropriate for you. A treatment is not guaranteed. In accordance with the privacy act (1988) all information collected is treated as "sensitive information". To protect your privacy, My Skin Pharmacy operates in accordance with the act. Australian Federal Privacy Laws require the pharmacy to receive your consent to collect your personal medical information.Your medical information will be used exclusively for the purpose of providing health care and treatment.Skincare Consult Price: Total
