Name
Address
City
Post code
Phone number
Format: (000) 000-0000.
D.O.B
Email address
example@example.com
Patient Profile
I am currently using or have used Accutane (isotretinoin) in the last six months
am pregnant or nursing/lactating
have allergies
have a skin infection/open wound on my face at present
am allergic to aspirin (acetylsalicylic acid)
have had a chemical or enzyme peel within the last 14 days
have had laser hair removal within the last 14 days
have had a photofacial treatment within the last 14 days
have had radio frequency skin tightening treatments within the last 14 days
have had a microdermabrasion treatment within the last 14 days
have had waxing, threading, or any other form of hair removal in the last 7 days
have you been exposed to the sun or used a tanning bed in the last 3 weeks
am currently using sunless tanning products
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
currently using AHA/BHA skin care products
am using any prescription topical medications at this time
wear contact lenses
have permanent make up
participate in aerobic physical activity
have had a cold sore in my lifetime
have used skincare products that caused an adverse reaction
None of the above
Do you have any medical issues?
Please list any medications or supplements you currently take:
Which of these statements is most applicable to you?
would like to look better for my age
would like to change something that has been bothering
would like to look more attractive
Have you had an aesthetic consultation or treatment before?
Yes
No
How often do you think about having an aesthetic treatment?
Most days
Weekly
Monthly
When I think about my appearance, I feel I look- Please tick three
Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive
After treatment I would like to feel-Please tick three
Fresher
Happier
Brighter
More awake
More youthful
More attractive
More illuminous
More confident
After treatment I would like to
What is your main skin concern?
When did you first notice your concern?
Do you notice your skin concern gets worse at any time of the day/month/year?
Current skincare routine:
Morning Routine
Evening Routine
Do you exfoliate in the week?
Do you wear sunscreen?
How is your current skincare regimen helping you?
Which of these in-clinic treatments interest you?
Skincare
Chemical Peels
Facials
Dermaplaning
Skin Tightening
Skin Injectables
Micro-needling
Skin booster
Muscle relaxant injections
Facial Fillers
How did you hear about us?
My doctor
Recommendation
Search engine
Social media
Preferred contact details
Phone:
Email:
Address
Please upload a photo of your face makeup free in ntaural light.
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