Online Consultation | Balance Clinic

Name *

Phone *

Email *

Date of Birth *

What is the main reason for getting in touch with us? *

Which of these statements is most applicable to you? *

I would like to look better for my age

I would like to change something that has been bothering

I would like to look more attractive

Have you had an aesthetic consultation or treatment before? *

Yes

No

How often do you think about having an aesthetic treatment? *

Most days

Weekly

Monthly

When I think about my appearance, I feel I look- Please tick three *

On a scale of 1 – 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your overall appearance? *

On a scale of 1 – 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin? *

After treatment I would like to feel-Please tick three *

List your desired outcomes in order of priority *

What are your main skin concerns? *

When did you first notice your concern? *

Do you notice your skin concern gets worse at any time of the day/month/year? *

What is your current skincare routine? *

Do you exfoliate in the week? *

Yes

No

Do you wear sunscreen? *

Yes

No

How is your current skincare helping your skin? *

Which of these in-clinic treatments interest you? *

How did you hear about us? *

Preferred contact method: *

Phone

Email

Consent *

I consent to this data being collected and in the event of an adverse reaction, I consent to the clinic passing this information to AlumierMD for further advice

Please upload images showing the areas you'd like to be treated.

Maximum upload size: 516MB

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