Pregnancy Consultation

Personal Details

Name*

Date Of Birth*

Email*

Phone*

Address*

General Information

How much is a consultation?

There is a €50 deposit taken at booking which is then redeemable if you spend €80 or more off products that are purchased on the day of your consultation. If you decide to not purchase products then the consultation cost €50 is not redeemable.

How can I get a consultation?

Fill out the form below with as much detail as possible and pick a day and time that suits you for our team to give you a call. Must be between 9am and 7pm. We will call you at the chosen time. You can also choose either a zoom call or a phone call, which ever you prefer.

What happens after your consultation?

As part of your consultation process you will receive 2 follow up calls from our skin team. We are here to support you through your skin journey. We do not charge for this follow up. We arrange to call you 4-6 weeks after your initial consultation, to check that all is going well and that you understand how to use the products correctly and see if any tweaks to your routine are necessary. After this we schedule one more call 4-6 weeks later which is free of charge also here we make sure that you are reaching optimum skin health. Follow up calls after this time will be charged at €25 which is fully redeemable against any products purchased that day over the phone. Once you continue to be a Touch and Glow client we are here to support and guide you throughout your Skin health journey.

Medical Consent

Please tick the appropriate box below

Are you currently taking any medication prescribed by a GP or any other practitioner?*

Yes
No

If yes please please provide further information

Are you currently taking any medication containing vitamin A?*

Yes
No

If yes please please provide further information

List any vitamins / supplements that you take regularly?

Are you currently pregnant, planning pregnancy or breastfeeding?*

Yes
No

If yes please please provide further information

What changes have you found in your skin?

Are you taking any supplements or probiotic?*

Yes
No

If yes, please list them here:*

What trimester are you in?*

What is your ultimate skin goal?*

Are you attending any GP or other practitioner for any other conditions?*

Yes
No

If yes please please provide further information

Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?*

Yes
No

If yes please please provide further information

Skin Questionnaire

Please tick the appropriate box below

What is your skin type?*

Dry (Eg Tight, Dull & Flakey)
Oily (Eg Breakouts, Blackheads & Shiney)
Combination (Eg Dry Cheeks, Oily T-Zone)
Normal (Eg Balanced & Smooth)

What are your main skin concerns?*

Fine Lines
Wrinkles
Enlarged Pores
Pigmentation
Acne
Redness Rosacea
Uneven Skin Tone

Do you have a history of the following?*

Smoking
Sunbeds
No

How sensitive would your skin be?*

Mild
Moderate
Very Sensitive
Not Sensitive

Do you apply spf daily?*

Yes
No

Are your prone to or currently have the following?*

Do you get any of the following?*

Comedones/Blackheads
Pustules/White Heads
Cystic Acne
Occasional Spots
Hormonal Breakouts
Never Breakout

What products are you looking for (Or Recommended)?*

Environ Skincare
Image Skincare
Caci Skin Treatments
Skingredients Skincare
DMK Skincare
Heliocare SPF

Are you happy with your current skincare & seeing results?*

Yes
No

What are you unhappy with about your skin?

What are you happy with about your skin?

Do you wear make up daily?*

Yes
No

Do you wear mineral make up?*

Yes
No

Would you like more info on mineral make up?*

Yes
No

What body ranges are you interested in?

Yonka Aroma Infusion
Lycon Body Scrubs

Tell me what your diet is like?*

Do you have health concerns or auto immune disorders?

Rate your level of stress 1-5, 5 being the highest.*

What is your current skincare routine? Please complete each below.

Cleanse*

Toner*

Serum*

Moisturiser*

Mask*

Eye Cream*

Do you do this AM and PM and is there anything additional you use on the skin that’s not listed above?*

Would you be interested in our home facial kit?*

Yes
No

Do you have a nut allergy?*

Yes
No

What are your skincare goals/what would you like to achieve*

Images Of Skin

Please upload the following for a member of our team to analyse your skin and you skincare recommendations.

Front*

Accepted file types: jpg, gif, png, Max. file size: 3 MB.

Right Side*

Accepted file types: jpg, gif, png, Max. file size: 3 MB.

Left Side*

Accepted file types: jpg, gif, png, Max. file size: 3 MB.

I agree I have given the correct information above.

Are you attending any GP or other practitioner for any other conditions?*

Yes
No

For your consultation what would you prefer?*

Zoom / WhatsApp Call Option
Email Option

Additional notes.

Consultation Fee*

Price:

Total

€ 0.00

Card Details*

Card Details

Cardholder Name

Personal Details

General Information

Medical Consent

Skin Questionnaire

Images Of Skin

Title

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