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info@lumadoc.ie

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.

    Q1.What treatments are you interested in?

    Q2. Within the last year, have you been under a dermatologist or another physician’s care

    If yes, please specify

    Q3. Have you had any health problems in the past or present?

    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?

    If yes, please specify

    Q5. Do you use Accutane, Renova, Adapalene or any other prescribed skin products?

    Q6. Have you ever had a reaction to any of the following?

    Q7. How would you prefer to be contacted?

    Q8. When would you prefer to be contacted?

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