Name *

First Name

Last Name

Phone

(###)

###

####

I am currently using or have used Accutane (isotretinoin) in the last six months? *

Yes

No

I am pregnant or nursing/lactating? *

Yes

No

I have allergies? *

Yes

No

I have a skin infection/open wound in the treatment area? *

Yes

No

I am allergic to aspirin (acetylsalicylic acid)? *

Yes

No

I have been exposed to the sun or used a tanning bed in the last 3 weeks? *

Yes

No

I am currently using sunless tanning products? *

Yes

No

I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)? *

Yes

No

I am using any prescription topical medication at this time? *

Yes

No

I have used skincare products that caused an adverse reaction? *

Yes

No

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

Dull

Tired

Sad

Angry

Old

Fresh

Happy

Bright

Unattractive

Which of these apply to your skin?

Lines

Wrinkles

Decreased Volume

Loss of elasticity

Glycation (criss-cross wrinkles)

Dryness

Blackheads

Whiteheads

Cysts

Acne Scarring

Sallow (yellow/dull) complexion

Oiliness

Open pores

Hyperpigmentation (brown spots)

Hypopigmentation (white spots)

Uneven Skintone

Freckles

Broken capillaries

Inflammation

Redness

Sensitivity

How did you hear about us?

Adverts

Recommendation

Search Engine

Social Media

Preferred contact details? *

Phone

Email

Address

I am happy for my before and after images to be used on Cuties Social Media *

Yes.

Yes (but cropped only to protect my identity)

No.