Name*Email* Phone*Residence*ResidenceNSWQueenslandOther Australian statesInternationalWhat is your ethnicity?*What is your ethnicity?Caucasian / EuropeanAsianMiddle Eastern / LatinoIslander / indigenousOtherMixedSkin concern?*Skin concernMelasmaEthnic - Asian pigmentAge spotsPost inflammatoryUnknown pigmentAcne scarsWrinkles & rejuvenationBirthmarkOthersHow long have you had your concern for?How long have you had your skin concern?Less than 3 months3- 12 months12 to 36 monthsLonger than 3 yearsUpload up to FIVE picture of your concern in natural light without makeup* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, heic, jpeg, Max. file size: 2 MB, Max. files: 5. Photos & clinical information is treated with the utmost confidentiality. This form is designed to expedite your application process for an appointment with our clinicians. Following review by our clinicians, we may grant you an appointment, should you want to see us. If our team is not taking on new patients, we will suggest a practitioner that may assist you. What have you tried so far for your concern?* Skin care Lasers Chemical peels Microneedling Injectables Others Please elaborate more on your problem including treatment success & failures, including who you have consulted for this problem (if any).*Scope of practice.* Our clinic focuses on advanced treatments including lasers, injectables & novel peels to deliver visible results. While we don’t primarily manage medical skin conditions such as acne, rashes, medical causes of pigmentation or allergies, we work closely with trusted medical dermatologists and will guide you to the right specialist when needed. This way, you’ll always receive the best care for your unique skin concerns. If your condition can be managed virtually, we will offer you more on this service URLThis field is for validation purposes and should be left unchanged.
