My Skin Consultation

Please note that you will need to complete the form below when purchasing a product that may have active ingredients

First Name

Last Name

Email

Date of Birth

Gender

Male

Female

Skin Type

Normal / Combination

Dry / Sensitive

Oily

Skin Conditons (Tick all that apply)

Acne - Inflammation

Eczema - Red

Rosacea - Redness

Sensitive / Sensitized Skin - Chronic redness

Ageing - Wrinkles / fine lines

Hyperpigmentation - Hormonal / post inflammatory / dark spots

Sun Damage - Regular extensive exposure to the sun

General Health

Auto-Immune Disease - Lupus, MS

Pregnant or Breastfeeding

Cortizone / Hydropcortizone - currently or recently

History of reaction to Active ingredients

Herewith I confirm that the information I have supplied is true and relevant. I acknowledge that there may be Active ingredients in the indicated products and that I have read the terms and conditions on the website.

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reception@acentreolympia.com

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