TMC SKIN SHOP

Please contact me on 07581212951 if you have any questions or need any help with submitting a direct order online via our skin shop 

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* 1. First Name:

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* 2. Surname:

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* 3. DATE OF BIRTH

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* 4. EMAIL ADDRESS

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* 5. CONTACT NUMBER

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* 6. Full Address (This will also be used as your delivery address for any skin products we will send out to you):

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* 7. Which describes you best?

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* 8. Have you used any medical grade products before? If yes, Which ones?

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* 9. Which best describes your skin condition?

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* 10. What is your Skin Type? 

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* 11. Do you have Sensitive Skin 

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* 12. Do you have any Allergies? If Yes, please state them below. If no, please type 'none':

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* 13. In your own words, what do you dislike about your skin? 

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* 14. What are your main concerns? 

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* 15. Would you consider in clinic treatments if we think its necessary alongside your at home skin care? To get the best outcome we may need to recommend some in clinic treatments as well as your new 'At Home' skin routine 

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* 16. Have you used Roaccutane for Accutane in the last 6 months? 

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* 17. Are you allergic or sensitive to any of the following: 

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* 18. Are you currently undergoing any treatment for autoimmune disease or anti- cancer treatment? such as radiation or chemotherapy 

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* 19. Have you had any of the following within the last 2 weeks ( Facials including Chemical peels, Facial Lasers? Such as Laser Hair removal or Skin Resurfacing Laser, Dermal fillers, Skin Boosters or Botulinum Toxin, Any surgical treatments on the face, or any other skin care treatments not stated above. If yes, please state below which ones we may need to know about? 

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* 20. Are you pregnant, breastfeeding or currently undergoing/ planning to undergo IVF within the next 6 months?

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* 21. What is your Skin Goal?

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* 22. Please upload a clear photo of your skin in normal daylight, no filters. Your photo must be of your full face, front view. A full face photo is necessary for medical purposes and will not be shared with anyone other that The Medical Clinic for review. 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 23. What is a reasonable budget to achieve this goal? 

Thank you for taking the time to complete our online consultation form. Our Skin experts will review your form and contact you within 48 hours with your treatment plan. Your personalised and bespoke skin care routine & prescription will be sent to you via the provided email. Please note: photo/ video consultation is required before purchasing any medical grade skincare. if you were unable to load your photos in this form please email them to enquiries@themedicalclinic.co.uk

We are excited for your new skin journey!
TMC Skin Team x

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* 24. Which products are you interested in purchasing? (If you don’t know just say- I don’t know)

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