I am currently using or have used Accutane (isotretinoin) in the last six months
I am pregnant or breastfeeding
I have allergies
I have a skin infection/open wound in the treatment area
I am allergic to aspirin (acetylsalicylic acid)
I have been exposed to the sun or used a tanning bed in the last 3 weeks
I am currently using sunless tanning products
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
I am using any prescription topical medications at this time
I have used skincare products that caused an adverse reaction
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 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?
How often do you think about having an aesthetic treatment?
When I think about my appearance, I feel I look- Please tick three
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?
After my treatment/ starting my skincare routine I would like to feel-Please tick three
What are your main skin concerns?
When did you first notice your concern?
Which of these apply to your skin?
Loss of elasticity (saggy skin)
Glycation (criss-cross wrinkles)
Sallow (yellow/dull) complexion
Hyperpigmentation (brown spots)
Hypopigmentation (white spots)
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine?
How effective have you found your current skincare routine in helping your skin?
Are there any specific products you would like to try?
Which of these in-clinic treatments interest you?
Muscle relaxant injections
Fat reduction face
Fat reduction body
How did you hear about us?
Preferred contact details
Take Photo: Front
Take Photo: Right Side
Take Photo: Left Side
I hereby confirm that the above information is correct and that I will notify Revitalise Medical Aesthetics should there by any changes. Signature:
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