ONLINE Skincare Consultation Form You can simply pop us an email at info@lumadoc.ie, or feel free to complete the form below, stating that you wish to take part in our free service and we will get back to you will all the information from there. Your Age12-1819-2526-3233-4041-50>51 Q1.What treatments are you interested in? Q2. Within the last year, have you been under a dermatologist or another physician’s care Please selectNoYes If yes, please specify Q3. Have you had any health problems in the past or present? Please selectNoYes Please list any Medications, Supplements, Vitamins, Diuetics, Slimming Tablets etc. that you take regulary Q4. Do you have any special skin problems pertaining to your face and body? Please selectNoYes If yes, please specify Q5. Do you use Accutane, Renova, Adapalene or any other prescribed skin products? Please selectNoYes Q6. Have you ever had a reaction to any of the following? CosmeticsPollenAnimalsMedicineFoodFragranceLodineHydroxy AcidsSunscreens Q7. How would you prefer to be contacted? Phone CallVideo CallEmail Q8. When would you prefer to be contacted? MorningAfternoonEvening