Environ Skincare Online Purchase Form-the-beauty-place

Environ Skincare Online Purchase Form

Please fill in the following details of this short questionnaire and we will respond to your request as soon as possible. All information given is treated as confidential.

First Name

Last Name

Phone Number

Address Line 1

Address Line 2

Town/City

County

Post Code

Country

Date of Birth

WELCOME TO HEALTHY SKIN

Please answer the following questions

Gender

Have you used Environ products before?

If yes, please describe your skincare regime in full:

Are you currently taking any prescriptive medication including topical creams?

If yes, please give details on the medication you are currently taking:

200

Do you have any allergies? If so, please specify below:

Are you pregnant or planning pregnancy?

Have you used Roaccutane (prescribed oral medication for Acne) in the last 3 months?

If yes, please advise on the exact date your course finished?

Any other information? E.g. Your most recent order number if you are completing immediately after ordering:

Please ensure the details on this form match the details on your order. Please note, without all of the above questions being completed, and your current Environ regime being described in full we will be unable to process your order.

Please check this box if you would like to be contacted to arrange a full Skin Health consultation at our Hove clinic.

Please check this box if you would like to be contacted to arrange a full Skin Health consultation online or over the phone.

DECLARATION

This form, including any additional data described above, is an accurate reflection of my current health and discloses all relevant medical conditions. I understand that it is my responsibility to disclose any changes to this data prior to each subsequent purchase.

I understand that to achieve optimal results, a full Skin Health consultation is recommended so that we can advise of the correct skincare products personal to you. I understand that results may vary in different treatment areas and that results are not guaranteed.

PRIVACY POLICY

We never share your information with anyone else.

We comply with the requirements of the General Data Protection Regulation (GDPR), regarding obtaining, storing and using personal data. Our full Privacy Policy can be found on our website.

Your Signature

Date

I want to subscribe to the mailing list.