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Bella & Me are available to do virtual consultation to help you choose the correct product for your skin. Please fill in the details below and we will schedule a consultation.

Name*

Email *

Date Of Birth* Phone Number* Occupation* Are you on any Medication?

No

Yes

If you are on medication please list all mediactions you are taking below:

Have you ever been treated for: (Please check applicable)

Acne

Depression

Cold Sores

Diabetes

Skin Disease

Cancer

High Blood Pressure

List any allergies you have below:

Are you pregnant?

No

Yes

Trying to get pregnant?

No

Yes

Are you currently Breast Feeding?

No

Yes

Current level of stress from 1 - 10? (1) being not stress at all and (10) being highly stressed

How many glasses of water do you drink per day?

Please list below any supplements/vitamins you are currently taking:

Do you exercise?

When you go out in the sun, do you? (Check one)

ALWAYS BURN

USUALLY BURN

SOMETIMES BURN

RARELY BURN

VERY RARELY BURN

What skin line are you currently using?

Do you use a daily environment protection product (sun block)? If not is there a reason why?

How do you feel about your overall quality of you skin? Please enter a number between 1 and 10. 1 not happy at all, 10 extremely happy.

Your skin type is?

NORMAL

DRY/DEHYDRATED

OILY

ACNE/ACNE PRONE

ROSACEA

What are your main skin concerns? Please check appropriate

Reduction Of Fine Lines

Acne Scares Diminished

Reduction of Brown Spost/Sun Damage

Reduction Of Redness

Reduction Of Oil/Acne

Is there anything else you'd like to improve about you skin.

Pease add your Initails to verify the above information is correct.

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We’re way beyond happy and proud…

Our customers agree that Bella and Me is the best salon in Maynooth and North Kildare, with 100% 5-star reviews on Google.

Phone: +35319041878

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