Environ:Instrument Cleaning Solution

*ARE YOU CURRENTLY TAKING ANY PRESCRIPTIVE MEDICATION INCLUDING TOPICAL CREAMS? Yes No

IF YES PLEASE ADVISE THE MEDICATION YOU ARE CURRENTLY TAKING:

*ARE YOU TAKING ANY VITAMIN SUPPLEMENTS? Yes No

IF YES, PLEASE ADVISE THE VITAMIN SUPPLEMENTS YOU ARE CURRENTLY TAKING:

*DO YOU HAVE ANY MEDICAL ALLERGIES OR CONDITIONS?

*ARE YOU PREGNANT / TRYING TO BECOME PREGNANT OR BREASTFEEDING? Yes No

*HAVE YOU USED ENVIRON PRODUCTS BEFORE? Yes No

PLEASE DESCRIBE YOUR CURRENT SKINCARE REGIME IN FULL:

*HOW WOULD YOU DESCRIBE YOUR SKIN TYPE? Oily Dry Sensitive Combination Normal Other

PLEASE PROVIDE ANY RELEVANT FURTHER INFORMATION ON YOUR SKIN:

*ARE THERE ANY PARTICULAR PROBLEM AREAS YOU ARE CONCERNED ABOUT? Anti-ageing Rosacea Pigmentation Acne