Skin Treatment Consultation

Skin Treatment Consultation

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Name*

First NameSurname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile number*

Phone Number
Date of Birth*

DayMonthYear
Date
What treatment(s) are you having*

Any Dermalogica Skin TreatmentNon Surgical Facelift (Microneedling)Chemical Peel TreatmentBody TreatmentsMelanoProNot sure yetOther
Skin Goals
List products you currently use (optional)
Do you have any concerns with the following:*

Uneven TextureFine lines and wrinklesEnlarged poresOily shineBreakoutsPigmentationEczemaPsoriasisRednessDehydrationBroken CapillariesDark under eye circlesAcne ScarringNone of the aboveOther
Skin Type*

OilyDehydratedCombinationDrySensitiveNormalTeenage Problem skinI’m not sure
Do you have a history of acne?*

YesNo
Do you use RetinA?*

YesNoOther
Have you ever used Accutane?*

YesNo
Do you use any product’s containing the following ingredients ?*

Glycolic AcidLactic AcidAny Exfoliating ScrubsAny other Hydroxy AcidsVitamin A Derivatives (like Retinol)NoOther
Have you had a chemical peel, microdermabrasion, cryosurgery, plasma pen or any other skin resurfacing treatment (ablation) in the last 3 months?*

YesNoOther
Have you had facial waxing/threading/bleaching/ electrolysis in the last 72 hours*

YesNo
Have you had any injectables (filler/botox/collagen/skin boosters/ fat or filler dissolvers/PDO threads) in the facial area in the last 6 weeks?*

YesNoOther
Any Laser (hair or skin)or IPL in the last 6 weeks?*

YesNoOther
Do you sunbathe or use sunbeds regularly?*

YesNoSometimes
Do any of the following apply to you?*

PregnantTrying to fall pregnantNursingPeri-menopausalMenstruatingPre-menstrualNo
Are you taking HRT? If yes please give details
Are you taking any Contraception? If yes please give details
List any allergies
Do any of these apply to you?*

EpilepsyMetal pins/ImplantsHigh/Low Blood PressureDiabetesOther Digestive ProblemsPacemaker or other electronic implantsCancerChemotherapyRadiationThrombosisPhlebitisHearing AidsViral infections such as Herpes Simplex (cold sores), cold, fluContagious skin diseaseLoss of Skin SensationContact lenses/glassesBody PiercingsSinus ProblemsClaustrophobiaHIV or HepatitisKeloid ScarringBroken Bones/injuriesVitiligoLow Immune SystemRecent Surgery/Scar TissueUndiagnosed Lumps or LesionsNeurological DisordersHigh TemperatureFungal Infections such as ringwormHead LiceOpen wounds/Bruises/SwellingCardiovascular conditionsBacterial Infections such as Impetigo and ConjunctivitisTatoo or semi-permanet make-up in the treats areaPolycystic Ovarian SyndromLupusHaemophilia or other blood disorderMedical OedemaKidney ProblemsAuto Immune diseaseRegular Urinary Tract InfectionsGastric UlcersThyroid ProblemsAlcohol or drug abuseDepressionMigrainesMuscular/Skeletal disordersSunburnNone of the above
List any others medical conditions and medications (like NSAID’s, Steroids, Antibiotics etc) and if under a doctor or specialist's care please give details.*
Have you been hospitalised or have had any surgeries in the last 6 months? If yes please give details. *
List any supplements, vitamins, diuretics, slimming pills, oral contraceptives etc. that you take regularly*
Disclaimer

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The procedure contraindications, precautions and warnings have been explained to me including alternative methods, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be fully anticipated. Therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the results of these treatments with are not permanent as natural degradation will occur over time. I have read this consent form and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment, including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.
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