Perfect Skin Direct: Online Skin Care Consultations
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Online Skin Care Consultations

With all products, professional advice is advised. At Perfect Skin Direct all our therapists are highly trained skin care professionals who have been Dermalogica trained at the highly acclaimed International Dermal Institute.

Once we receive your consultation form, and any concerns you may have, one of our therapists will analyse this and give you prescriptive skin care recommendations within 24 hours, Monday to Friday.

Contact Details  
Name:
Address:
Phone:*
Email:
Age: Under 21
21-30
31-40
41-50
51-60
60+
Your health  
Within the last year, have you
been under a physician's care?
Yes
No
Within the last year, have you
been under a dermatologist's care?
Yes
No
Within the last nine months,
have you undergone any surgery?
Yes   Specify:
No
Have you had any of these health
problems in the past or present?
Cancer
Diabetes
Epilepsy
Heart problem
Hormone imbalance
Spinal injury
Hysterectomy
Thyroid condition
Varicose veins
Systemic disease
List medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly:
Do you smoke? Yes
No
Do you follow a restricted diet? Yes
No
Do you have regular sleep patterns? Yes
No
Do you wear contact lenses? Yes
No
Do you have metal implants or a pacemaker? Yes
No
Your Skin  
With what temperature of water do you cleanse? Cool
Warm
Hot
Do you have any special skin
problems pertaining to your face or body?
Yes   Specify:
No
What skin care products are
you currently using?
Soap
Cleanser
Toner
Moisturiser
Masque
Exfoliator
Eye products
Others
Exfoliation History  
Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments? Yes
No
In the last month? Yes
No
Do you use Accutane, Retin A, Renova or Adapalene? Yes
No
In the last 3 months? Yes
No
Do you use an acne medication? Yes
No
In the last 6 months? Yes   Specify:
No
Are you currently using any products that contain the following ingredients? Glycolic acid
Lactic acid
Any exfoliating scrubs
Any hydroxy acid product
Vitamin A derivatives
      (i.e. retinol)
Moisture Hydration  
How much plain water do you consume daily?
How many alcoholic beverages
do you consume weekly?
Do you ever experience these
conditions on your skin?
Flakiness
Tightness
Obvious Dryness
What spf sunscreen do you use on your face?
What spf sunscreen do you use on your body?
Do you sunbathe and/or use tanning beds? Yes
No
Capillary Activity  
Do you burn easily in moderate sunlight? Yes
No
Do you blush easily when nervous? Yes
No
Do you have a tendency to redness? Yes
No
Do you suffer from sinus problems? Yes
No
Oil Secretion  
Do you ever experience oily shine during the day? Yes
No
Occasionally
Do you ever experience skin breakouts? Yes
No
Occasionally
Nerve Activity  
Do you drink caffeinated beverages? Yes   Daily:
No
Do you ever experience a burning,
itching sensation on your skin?
Yes
No
What is your pain threshold? Low
Medium
High
Have you ever had a reaction
to any of the following?
Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy acids
Animals
Fragrance
Sunscreens
Female Clients Only  
Are you taking oral contraception? Yes
No
Are you pregnant or trying to become pregnant? Yes
No
Are you lactating? Yes
No
Male Clients Only  
What is your current shaving system? Electric Shave
Wet Shave
Do you experience irritation from shaving? Yes
No
Do you experience ingrown hairs? Yes
No
Your Skin Goals:
Additional Comments:
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