Call Us Today: Landline: 08 93671877 | Mobile: 0410 971 877 info@covespa.com.au

MEDISPA ONLINE CONSULTATION FORM

Please complete the following consultation form and upload a clear, close photograph of your skin and we will analyse your skin online providing the photograph is clear. If we have further questions we will be in touch. If you are ordering the OCosmedics Introductory Offer, we will email you an invoice which you can pay online. On receipt of payment we will have your brand new OCosmedics skin care in the post and on its way, along with a gift card for your Pro Dermal Peel valid for 1 month. If you are seeking a quote for an Advanced Skin Treatment program, please continue with the form below.

 

Please tick any of the following that are relevant to your current state of health:

Skin ConditionsCancerDiabetesHigh/Low Blood PressureVaricose VeinsHeart ConditionsEpilepsyM.SAnxietyClaustrophobiaDepressionHIVCurrent InjuriesRecent SurgeryLymphatic issuesMetal PlatesPace MakerEczema/Dermatitis/Psoriasis


Please let us know how your skin feels currently?
DrySensitiveOily/Combination/BreakoutsDehydratedRednessCongestion/BlackheadsAgeing?Pigmentation?
Please tell us about your current homecare routine. Please specify how frequently you use skin care products and which brands.

Which product do you currently Cleanse/Exfoliate with and how often?
Do you use a Serum?
Which Brand/s?
How often?
Do you use a Moisturiser/Hydrator?
Which Brand/s?
How often?
Do you use a an eye cream?
Which Brand/s?
How often?
Do you use a Mask?
Which Brand/s?
How often?
Do you use an SPF?
Which Brand/s?
How often?
Do you use Foundation/Luminiser/Blush?
Which Brand/s?
How often?
Which shampoo and conditioner brands do you use?
Are you currently using/have had any time in the past 6 months?

Retinol/Vit ARoaccutaine/Acne MedicationsGlycolic Fruit Acid/BHA/AHABotox/InjectablesSkin Tightening/Fraxel LaserIPL or Laser/Skin Needling/CIT

Please upload a clear, close, make up free selfie of your skin and we will send you an invoice with a list of your essential skin care. Your photo will be analysed by Management in our highly professional environment. Please be advised all photos are kept securely and are strictly private and confidential. We aim to reply within 1-3 days.

Upload Image:
Upload Image:
Upload Image:
Upload Image:
Comments
I have read the above information and understand that I personally take full responsibility for my decision for treatments and waiver Cove Spa and the operator of any liability. I agree the information I have completed is correct to my knowledge and I have not withheld any information that could be relevant to my treatment.

Signature
Date