Environ Consultation Form

Thank you for your order! Before we can ship your order, you must complete this consultation form below. This is a requirement by Environ for all Environ products sold online.

If you have previously ordered Environ from us, please skip this and go to the 'Contact Us' tab above and input your details to the Environ & Alumier Order review section

Order Number *

Name

Phone

5. Email address *

1. Are you using Environ products? *

Yes
No
I have previously used them

If yes, which clinic have you had an Environ consultation with?

Does your order contain an Environ step-up programme product? *

Have you purchased an Environ product this time that you haven't used before? *

Yes I have
No I haven't

Skincare Routine

Please provide as much detail about your skincare routine as possible so that we do not need to do a follow up call and we can release your order. Please include products you are currently using and products you have recently used. Include brand names and exact product names and types *

Skin Conditions

Tick all conditions that apply *

Fine lines and wrinkles
Eczema
Psoriasis
Dark Circles
Scarring
Cellulite
Acne / Breakouts
Redness / Rosacea
Stretch Marks
Pigmentation
Keratosis Pilaris
No skin conditions

Skin type (tick any that apply) *

Normal Skin
Oily Skin
Combination Skin
Dry Skin
Sensitive Skin
Dull Skin

Medical Information

Do you have any medical allergies? *

If yes, please specify

Are you currently breastfeeding, pregnant or trying to conceive? *

Thanks for your submission! If your consultation raises any issues for concern somebody from our team will be in touch, otherwise your order will be shipped immediately after review

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