Before your visit

Pre-visit Intake

This helps your practitioner prepare. It takes a few minutes, uses text only (no uploads), and is stored securely for your consultation. It is not a diagnosis.

About youName *Email *Phone (optional)Region & time zoneAge

Your main concern & goalsWhat's your main skin/health concern, and when did it start?What are you hoping to achieve?

Skin & medical historySkin type and any past skin conditions or treatmentsRelevant medical historyAllergies (drugs, foods, skincare). Write 'none' if none. *Current medications & supplements. Write 'none' if none. *

I have a history of a severe allergic reaction (e.g. anaphylaxis).I take blood thinners / anticoagulants (e.g. aspirin, warfarin).I have a bleeding or clotting disorder.I have a history of cold sores (oral herpes).I currently have an active skin infection.I have had a fever recently.

Pregnancy & medication-specificPregnancy / breastfeeding statusI have taken isotretinoin (e.g. Accutane) in the last 12 months.

Lifestyle & current routineSleep, stress, exercise, diet, sun habits (brief)Your current skincare routine (brief)

Wellbeing

Your wellbeing matters. If you are in crisis, please use the resources below — you do not have to wait for a reply.

I am currently having thoughts of harming myself or others.

ConsentI agree that my information is used only to prepare for and provide my consultation, per the Privacy & Terms. (required)I understand an online assessment is not a diagnosis or prescription, and that I should seek in-person or emergency care for any acute or serious symptom. (required)You may contact me by email/phone about my consultation (optional).

Stored securely for your consultation. Not used for advertising; sensitive submissions are kept separate from analytics. Calendar/booking: hello@solaiment.example.