Please fill in the data and press the submit button to send your  profile to our medical team for an expert opinion.

You can also email your skincare concern to info@dermagenesis.com.my.  

* Indicates required fields.

Name *

Sex *

 Male

 Female

Age *

Occupation *

E-mail Address: *

Telephone number *

How did you reach our website? *

STAR newspaperTattler / PEAK magazineOther newpapersOther magazinesWhile surfingSearch enginesRecommended by friendsOthers

How should we contact you? *

 Phone

E-Mail

Skincare concern

Acne
Acne scars
Anti aging
Body skincare

Breast augmentation

Breast lift

Dull skin
Excessive sweating
Eyelid surgery
Facelift
Growth hormone
Hair removal

Hair restoration
Lip augmentation
Liposuction
Moles & skin tag
Nose reshaping
Open pores

Pigmentation
Scars - Chicken pox, post surgery...
Slimming - Cellulite, localized fat...
Spider veins
Tattoo removal
Wrinkles

Lifestyle

Sun exposure - normal
Sun exposure - high
Smoking
Under constant stress
Irregular menstrual cycle

Poor nutritional habits
Skin condition aggravating stress
Avoiding people due to skin condition
Skin exposed to environmental pollution
Tick the box if using sunblock

Previous cosmetic procedures

Any medical or surgical conditions

Any known allergies

Any other information

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE FOLLOWING: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional doctors. The medical doctors at DermaGenesis analyze and suggest treatments or advices solely on the completeness and accuracy of the information provided by you. Since medicine is not an exact science, newer discoveries are possible and the information provided here might be in conflict. Consumers are advised to seek professional medical advice as and when necessary.