Fire & Ice Consultation Form
SKIN CONSULTATION
Name
*
First Name
Last Name
Date of Birth
*
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Day
/
Month
Year
Date of birth
Email
*
example@example.com
Contact Telephone No
*
Telephone No
Address
Street Address
Street Address Line 2
City
County
Post Code
Client Signature
*
HEALTH
Are you currently seeing a Doctor for any medical conditions?
Yes
No
Are you taking any medications?
Yes (please list)
No
List of medications
Do you suffer from or use any of the following? Please tick appropriate box(es):
Cardiac Problems
Allergies (including aspirin)
Cancer/ Chemotherapy
Reactions to skincare / food
Claustrophobia
Diabetes (Type 1 of 2)
Polycystic Ovaries
Prone to Keloid Scarring
Recent Surgical Procedures
Epilepsy
Rosacea
Psoriasis/ Eczema
Contact Lenses
Asthma
Sunbeds
Claustrophobia
Smoking
Herpes Virus
KNOWN ALLERGIES to medication:
Allergy details
KNOWN ALLERGIES/SENSITIVITIES to prior skin care products or chemical peels:
Allergy details - skin care/chemical peels
How much water do you drink daily?
Water consumed
How much alcohol do you drink weekly?
Alcohol consumed
Do any of the following apply? Please tick appropriate box(es):
Pregnant
Nursing mother
Currently on menstrual cycle
SKIN HEALTH
What services have you had before to treat your concerns or improve your skin?
Previous treatments
What's your skincare routine? Please tick appropriate box(es):
AM - Cleanse
PM - Cleanse
AM - Exfoliation
PM - Exfoliation
AM - Serum
PM - Serum
AM - Moisturiser
PM - Moisturiser
AM - Sunscreen
How are those products treating your skin care concerns? Have you seen an improvement?
Skincare routine observations
Are you using active products that contain Vitamin A(Retinol), AHA/BHA’s?
Yes
No
In order of priority, what are your current skin concerns?
Skin concerns
When did you first notice your skin concerns?
Skin concerns - observation
Do you notice it is worse at any times of the day/ month/ year?
Skin concerns - worse at these times
CONSENT FORM
Before receiving your treatment, you are responsible for informing their skin care professional about any topical and/or oral medications or health conditions that may affect this procedure
Pregnant or possibility of being pregnant- depending on treatment
Nursing/breastfeeding- depending on treatment
Active cold sores, Herpes Type I or II, or warts in the treatment area*
Wounded, sunburned, excessively sensitive skin
Allergy to idebenone (synthetic antioxidant)
Vitiligo
History of autoimmune diseases including psoriasis, lupus, rheumatoid arthritis, dermatomyositis, multiple sclerosis, or any medical issues that may weaken the immune system
History of any diseases of immune deficiency
Inflammatory dermatitis conditions including rosacea, seborrheic dermatitis, systemic lupus erythematosus or dermatomyositis
Hyperpigmentation related to the prior use of hydroquinone-containing products
I understand although complications are very rare, they do sometimes occur. In this event, prompt treatment or modified instructions for home care may be necessary. If I suspect any complications or have concerns, I will immediately contact my skin care professional, or who I am directed to contact by (The AL5 Aethetics) for instructions.
I understand and agree direct or extended sun exposure without use of EXTREME PROTECT® SPF 30 and/or use of a tanning bed is not advised at any time.
I agree to follow my skin care professional’s recommended Home Care regimen provided to me after the chemical peel procedure to minimize possible side effects and maximize results
Customer Full Name
First Name
Last Name
Date of Signature
*
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Day
/
Month
Year
Date
Customer Signature
*
Skin Care Professional
First Name
Last Name
Skin Care Professional: Date of Signature
*
/
Day
/
Month
Year
Date
Skin Care Professional Signature
*
Submit
Should be Empty: