Natures Face Skin Consultation

To learn what Environ Skincare products are best suited to you, please provide these details which will then be passed on to our Environ® trained consultation staff. All data supplied will only be used by Natures Face .

For more informatiom on Environ®, their considerable Medical Research and their Skin Care Insitute in South Africa, please click on the links below, otherwise, please continue to the form:

ENVIRON® Medical Research

The ENVIRON® Skincare Insitute

To select multiple responses where necessary, hold down the CONTROL (ctrl) key and click on the responses required.

Personal Details

Name
Address
Date of Birth
Occupation
Home Tel:
Work Tel:
Fax:
Mobile:
Email:

Skin Details

Skin Quality
Skin Sensitivity
Skin Breakouts
Skin Type

History of your skin

Skin Description
Skin Elasticity
Wrinkles
Pigmentation
Acne Scars

Are you, or have you been treated for acne with any of the following?
Other, please specify:

Are you prone to any of the following?

If you are, is it localised or extensive?

Are you, or have you been treated with any of the following?
Other, please specify:
Please state the affected areas:

If you are, is it localised or extensive?

Are you, or have you been treated with any of the following?
Other, please specify:

Have you ever had any of the following?
Chemical peelings (Please specify)
Other skin care treatments (please specify)

General Health

Are you, or do you have any of the following?

Are you taking any of the following?
	Medication details
	Vitamin Supplement Details
Do you suffer from any known allergies, e.g. asprin?	Allergy Details

History of Sun Exposure

Do you use a sunscreen daily?
Do you, or have you done any of the following?

History of Products Used

Are you using Environ skin care products?
Please specify which products and duration of use
What skin care products have you used before Environ?
What other skin care products are you currently using?

Now that you have completed the Natures Face Skin Survey, please check your details and then click send.

Alternatively, please print this page and post your form to the following address:

Tel:	01453 882 110
Email:	info@naturesface.co.uk
Address:	Natures Face at Stables Cottage, Forwood, Minchinhampton, Gloucestershire GL6 9A GL6 9AB