Environ

Personal Details

Name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth*

Phone*

Email*

Skin Questionnaire

Welcome to Healthy Skin

Please answer the following Health questions

Are you prone to any of the following?

If yes, where and how long?*

Do you have a history of the following?

Sunbeds
Smoking
None of the above

What is your skin type?

How sensitive is your skin?

What are your main skin concerns?

Please indicate are you or do you have any of the following

These conditions are contraindicated to the Environ® DF Ionzyme® electrical treatments. + These require doctors consent

Select any which apply to you*

Any other medical conditions*

Yes
No

Please specify*

Any known allergies*

Yes
No

Please specify*

Sonophoresis Caution

Do you have any of the following?*

Select All
Hearing Implants
Tinitus

Have you been treated with any of the following?

Select any that apply*

Any other medication*

Yes
No

Please specify*

If you have answered yes, please indicate when and for how long*

Please indicate if you are having or have had any of the following

CST*

(immediately after treatment)

Yes
No

IPL*

(immediately after treatment)

Yes
No

Laser Treatments*

(wait 2 weeks)

Yes
No

Microdermabrasion*

(immediately after treatment)

Yes
No

Electrolysis*

(wait 2-3 days)

Yes
No

Facial Waxing*

Yes
No

Botox*

(wait 2 weeks)

Yes
No

Fillers*

(consult practitioner)

Yes
No

Other skincare treatments

If you have answered yes, please indicate when and for how long*

Your Environ Regime

Please feel free to upload photos of your skin, in particular any problem areas

Drop files here or

What is your current skincare routine? Please indicate which products you are currently using.*

What is it that you would like to achieve with your skin?

Once you submit this information your therapist will be in contact with you to take you through the next steps.

To submit this form, you need to accept our Privacy Statement*

Accept

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Comments

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Environ Skin Consultation

Personal Details

Skin Questionnaire

Welcome to Healthy Skin

Please indicate are you or do you have any of the following

Sonophoresis Caution

Have you been treated with any of the following?

Please indicate if you are having or have had any of the following

Your Environ Regime

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