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Please complete the following form to start your skincare consultation with our expert skin specialists.

Once completed and you have been assessed for suitability by our expert specialists, you will receive product recommendations in an email. The Environ Skin Care products will then be unlocked and eligible to buy in our exclusive online store.

Please note, online consultations are approved Mon-Fri 9am-5pm. If completed after 3pm then you will be assessed on the next working day. Please call or email [email protected]n.com

* = required information

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    About You

    [/vc_column_text][/vc_column][vc_column width="1/3"][vc_cf7_elements label="First Name *"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Last Name *"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Date of Birth *"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="no-padding-tb"][vc_column padding_setting="1" desktop_padding="padding-two-tb" width="1/1"][vc_column_text]

    Contact Information

    [/vc_column_text][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Email Address *"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Telephone Number *"][/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Preffered Contact Method *"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="no-padding-tb"][vc_column padding_setting="1" desktop_padding="padding-two-tb" width="1/1"][vc_column_text]

    Medical History

    [/vc_column_text][/vc_column][vc_column width="5/12"][vc_cf7_elements label="Do You Have Any Medical Conditions? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="7/12"][vc_cf7_elements label="If Yes, Please Provide Details"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="5/12"][vc_cf7_elements label="Are You Taking Any Medications? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="7/12"][vc_cf7_elements label="If Yes, Please Provide Details"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="5/12"][vc_cf7_elements label="Are You Taking Any Supplements? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="7/12"][vc_cf7_elements label="If Yes, Please Provide Details"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="5/12"][vc_cf7_elements label="Do You Have Any Allergies? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="7/12"][vc_cf7_elements label="If Yes, Please Provide Details"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Are Your Currently Taking Aspirin OR Blood Thinners? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Are You Currently Pregnant OR Breastfeeding? *"]YesNo[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column padding_setting="1" desktop_padding="padding-two-tb" width="1/1"][vc_column_text]

    Your Skin

    [/vc_column_text][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Do You Have Any Of The Following Skin Conditions?"]PsoriasisEczemaRosaceaAcne[/vc_cf7_elements][/vc_column][vc_column padding_setting="1" desktop_padding="padding-left-ten" width="1/2"][vc_cf7_elements label="Other (specify)"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="2/3"][vc_cf7_elements label="Have You Ever Experienced Skin Sensitivity To Any Products or Facial Treatments? *"]YesNo[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Have You Had Any Advanced Facial Treatments In The Last 6 Months? *"]LaserIPLPeelsMicrobdermabrasionInjectablesMicroneeding[/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Other (specify)"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Do You Have Any Previous History Of Skin Cancer? *"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Are You Prone To Sunburn? *"]YesNo[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="2/3"][vc_cf7_elements label="What Is Your Skin Complexion? *"]Very FairFairWhiteOliveDark BrownBlack[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="2/3"][vc_cf7_elements label="What Is Your Skin Type? *"]OilyCombinationSensitiveDryNormal[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Please State Your Skin Concern(s) (if any)"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Upload A Photo Of Your Skin Concern"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column padding_setting="1" desktop_padding="padding-two-tb" width="1/1"][vc_column_text]

    Other Information

    [/vc_column_text][/vc_column][vc_column width="1/2"][vc_cf7_elements label="What Skincare Products Are You Currently Using? *"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="What Are Your Skin Realted Goals? (those you are looking to address) *"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements label="Please Share The Specific Products You Are Interested In Purchasing? (for those attempting to order Environ Skincare Products through our website)"][/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements]I confirm to the best of my knowledge that the answers given are correct and I have not withheld any information. I understand that results cannot be guaranteed. I will inform PleijSalon.com if any of this information changes. *[/vc_cf7_elements][/vc_column][/vc_row][vc_row padding_setting="1" desktop_padding="padding-two-tb"][vc_column width="1/2"][vc_cf7_elements][/vc_cf7_elements][/vc_column][/vc_row]

    If you haven’t done so already, create a customer account at pleijsalon.com/register

    Once your consultation and account have been approved, you will be able to purchase Environ Skin Care products from our online boutique at pleijsalon.com/shop. These products are medical grade and exclusively available to our approved clients.

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