Skin Assessment Questionnaire

Looking for professional skincare advice? Confused about which treatments are suitable for your specific skin concerns? Simply complete our skin assessment questionnaire along with some high quality images and our skincare Doctor, Dr Joanna will review your submission and send you a free report on what treatments are available to help.

First name

Last name

Email

Phone

Birthday

Please tell us about any other skin concerns you have.

Please list any previous treatments you have had.

Please list any pre-existing medical conditions.

Are you currently taking any medications or supplements? If so, please list them below.

Are you currently pregnant or breastfeeding?

Please state anything else you think may be relevant to your skin concerns (eg. Menopause, excessive UV exposure, issues with previous treatments).

Are there any treatments that you are aware of that you are particularly interested in?

Please upload some high quality photos of your face. These should be taken in good lighting with the rear camera of your phone.

Front

File upload

45 degrees left side

File upload

45 degrees right side

File upload

Please upload close up pictures of any areas that are of particular concern.

File upload

Please let us know about any other questions, queries or concerns you may have.

Opening Hours

Monday

10:00 am - 4:00 pm

Thursday

10:00 am - 4:00 pm

Norwich Skin Clinic

Skin Assessment Questionnaire

Opening Hours

Norwich Skin Clinic