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Shop
About Us
Products
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Before & After
Make A Booking
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Contact

Registration Form

Please fill this out to the best of your ability and we will then contact you at an appropriate time to set up an over the phone skin consultation.

Bondi lash & beauty clinic

Personal Details

Name

First name

surname

Date of Birth

Address Line 1

Address Line 2

City

State

Contact no

Email address*

Password*

Used to create an account for you.

What are your concerns?

What are your looking for in skin care line?

Describe any hereditary history you may have

Any family history of cancer?

No

Yes

Lifestyle, How would you describe you health

Do you take vitamins?

No

Yes

Do you smoke?

No

Yes

Is your stress levels?

High

Medium

Low

Do you normally sleep well?

No

Yes

Do you exercise regularly?

No

Yes

How much liquids do you consume daily, eg water, coffee , tea

Current Skin Care Routine

Soap and water only?

Brand / type

Cleanse

Tone

Moisturiser

Exfoliation

Sunblock

Serums

Other

Medication

Have you ever used : Roaccutane or Retiniod acid

No

Yes

When did you start / finish

Have you used: Topical antibiotics, Topical cortisone

Medical conditions

Have you ever had any of the following: Fever blisters / cold sores / herpes

No

Yes

Acne, Since when? Where on the body was it?

Allergies e.g salicylate , sun creams , antibiotics

No

Yes

Since when? What symptoms and reactions on the body?

Have you ever had any of the following?

Diabetes

Type 1

Type 2

Eczema

Since when? What part of the body?

Epilepsy

Joint replacement

No

Yes

Heart disease

No

Yes

Pacemaker or valve replacement

No

Yes

Metal implants

No

Yes

Menopause / peri-menopause states

No

Yes

Hepatitis

No

Yes

Do you take oral contraception

No

Yes

Are you pregnant or trying to fall pregnant

No

Yes

Do you have a hormonal imbalance

No

Yes

Skin Type

Normal

Dry

Oily

Combination

Red / Sensitive

Do you ever experience: Flakiness or scaly skin, Redness, Tightness

Excessive oiliness or Hume during the day

Do you blush easily due to

Emotions

Foods

Temperate change

Other

Ageing, Fine lines and wrinkles, Dryness, Acne, Pigmentation, Scars, Skin cancer, Eczema, Reaches allergies, Others descripe…

Does your skin heal quickly / How quickly / Scar / Pigment easy

This field should be left blank

Thank you for filling out our consultation form and welcome to our online store. One of our experienced therapists will be in touch in the next business day. We look forward to helping you with your skin care journey.

Bondi Lash and beauty clinic.

The Beauty House Location

The Beauty House
(02) 9386 4330
Bondi Junction, 23 Bronte Rd, Sydney NSW 2022

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Our Services

Aduro LED Light Therapy
Advanced Skin Needling Dermapen 4
Body Treatments
Eye Treatments
Eyelash Extensions
Signature Facials
Peel Facials
IPL
Spray Tanning
Waxing

Aduro LED Light Therapy
Advanced Skin Needling Dermapen 4
Body Treatments
Eye Treatments
Eyelash Extensions
Signature Facials
Peel Facials
IPL
Spray Tanning
Waxing

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