New Client Questionnaire

Your Name

Your Email

Your Phone Number

How did you hear about The Clear Skin Clinic? (check as many boxes as appropriate)
InstagramFacebookGoogle SearchReferralOther

What skin conditions are you looking to treat?
AcneDry SkinOily SkinAnti-AgingBlackheadsPimplesTroublesome SkinOther

What kind of treatments have you had to treat your skin before?
General FacialsSpecialist FacialsExtraction FacialsLED Light TherapyChemical PeelsCool PeelsMicroneedlingMicrodermabrasionOther

What kind of treatments are you interested in at The Clear Skin Clinic?
General FacialsSpecialist FacialsExtraction FacialsLED Light TherapyChemical PeelsCool PeelsMicroneedlingMicrodermabrasionOther

Do you currently have an at-home skincare program?
YesNo

Is there anything else you think we should know about your skin?