DR KALY JAFF CONSULTATION FORM

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* 1. Please complete the following...

First Name

Surname

Your Email Address

Country of Residence

Your DOB

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* 2. Which describes you best?

I am new to Medical Grade Skincare

I have used Medical Grade Skincare before

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* 3. Which best describes your skin?

Aggressive Inflamed Acne

Minor Hormonal Breakouts

Blackheads & Oily Skin

Dry Sensitive Skin

Flushed Cheeks, Rosacea & Broken Capillaries

Dull & Tired Looking Skin

Ageing Skin

Sun Damage/Melasma Pigmentation (brown)

Post Inflammatory Pigmentation (purple)

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* 4. How would you describe your skin?

Mostly Oily

Mostly Dry

Normal

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* 5. Would you describe your skin as sensitive?

Yes

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* 6. Tell me in your own words what you dislike about your skin?

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* 7. What are your main concerns? (maximum of two choices)

Breakouts

Texture (bumps/blackheads)

Scarring

Dry Skin

Dull Skin

Ageing Skin

Uneven Skin Tone (discolouration)

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* 8. Have you used Roaccutane or Accutane in the last 3 months?

Yes

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* 9. Do you have any allergies?

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* 10. Are you allergic or sensitive to any of the following

Lactic Acid

Citric Acid

Salicylic Acid

Retinol (Vitamin A)

Latex

Asprin

None of the above

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* 11. Are you undergoing any type of radiation or chemotherapy?

Yes

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* 12. Have you recently had any facial, peels or skincare treatments we should know about?

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* 13. Are you pregnant or breastfeeding?

Yes

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* 14. Please upload a photo of your skin (medical requirement)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 15. What is a reasonable budget to achieve this goal?

£150

£200

£250

£300

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Your bespoke skincare routine & prescription will be sent shortly.