SECHI SKIN CLINIC CONSULTATION FORM

Name
Post code
Phone number
Email address
example@example.com
I am currently using or have used Accutane (isotretinoin) in the last six months

YesNo
I am pregnant or nursing/lactating

YesNo
I have allergies

YesNo
I have a skin infection/open wound in the treatment area

YesNo
I am allergic to aspirin (acetylsalicylic acid)

YesNo
I have been exposed to the sun or used a tanning bed in the last 3 weeks

YesNo
I am currently using sunless tanning products

YesNo
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)

YesNo
I am using any prescription topical medications at this time
YesNo
I have used skincare products that caused an adverse reaction

YesNo
If you answered YES to any of these, Please explain further
What is the ethnic background of your parents?
Do you have any medical issues?
What is the main reason for your enquiry today?
Which of these statements is most applicable to you?

would like to look better for my agewould like to change something that has been botheringwould like to look more attractive
Have you had an aesthetic consultation or treatment before?

YesNo
How often do you think about having an aesthetic treatment?

Most daysWeeklyMonthly
When I think about my appearance, I feel | look- Please tick three

DullTiredSadAngryOldFreshHappyBrightUnattractive
On a scale of 1 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your appearance?
On a scale of 1 - 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
On a scale of 1 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
After treatment I would like to feel-Please tick three

FresherHappierBrighterMore awakeMore youthfulSlimmerMore attractiveMore illuminousMore confident
What are your main skin concerns?
When did you first notice your concern?
Which of these apply to your skin?

Lines (superficial)WrinklesDecreased volumeLoss of elasticity (saggy skin)Glycation (criss-cross wrinkles)DrynessBlackheadsWhiteheadsCysts (boils)Acne ScarringSallow (yellow/dull) complexionOilinessOpen poresHyperpigmentation (brown spots)Hypopigmentation (white spots)Uneven skintoneFrecklesBroken capillariesInflammationRednessSensitivity
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine?
How is your current skincare helping your skin?
Are there any specific products you would like to try?
Which of these in-clinic treatments interest you?

SkincareChemical PeelsIPLMicrodermabrasionFacialsDermaplaningPigment reduction - cryotherapySkin TighteningSkin InjectablesMicro-needlingMesotherapyLaserMuscle relaxant injectionsFacial FillersFacial ThreadsBrow correctionThread vein removalFat reduction
How did you hear about us?

My doctorAdvertsRecommendationSearch engineSocial media
Preferred contact details

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