PRE-CONSULTATION QUESTIONNAIRE
Please answer a few quick questions so we can give you the best advice!

STEP One

PERSONAL DETAILS
Choose Your Online Preference Video Call

STEP Two

Skin questionnaire
Choose Your Skin Type*
Dry
Normal
Oily
Sensitive
Combination
Choose Your Skin Concerns*
Fine Lines & Wrinkles
Acne
Scarring/Acne Scarring
Enlarged Pores
Hyperpigmentation/Sun Damage
Rosacea
Dark Circles
Dry/Flaky Skin
Puffiness
Lack Of Elasticity/Drooping
Eczema
Broken Capillaries
Medical Info*
Skincare Products*
Describe In Small Detail What You Are Experiencing*
Unit 1, Mayor Street Lower, Dublin 1
13 Main Street, Dundrum, Dublin 14
www.havanaskinclinic.com
01 424 2010
book@havanaskinclinic.com
Copyright © 2020 - Havana Skin Clinic