Fire & Ice Consultation Form

Fire & Ice Consultation Form

SKIN CONSULTATION
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date of birth
Email*
example@example.com
Contact Telephone No*
Telephone No
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Client Signature*

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HEALTH
Are you currently seeing a Doctor for any medical conditions?

YesNo
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 ProblemsAllergies (including aspirin)Cancer/ ChemotherapyReactions to skincare / foodClaustrophobiaDiabetes (Type 1 of 2)Polycystic OvariesProne to Keloid ScarringRecent Surgical ProceduresEpilepsyRosaceaPsoriasis/ EczemaContact LensesAsthmaSunbedsClaustrophobiaSmokingHerpes 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):

PregnantNursing motherCurrently 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 - CleansePM - CleanseAM - ExfoliationPM - ExfoliationAM - SerumPM - SerumAM - MoisturiserPM - MoisturiserAM - 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?

YesNo
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 treatmentNursing/breastfeeding- depending on treatmentActive cold sores, Herpes Type I or II, or warts in the treatment area*Wounded, sunburned, excessively sensitive skinAllergy to idebenone (synthetic antioxidant)VitiligoHistory of autoimmune diseases including psoriasis, lupus, rheumatoid arthritis, dermatomyositis, multiple sclerosis, or any medical issues that may weaken the immune systemHistory of any diseases of immune deficiencyInflammatory dermatitis conditions including rosacea, seborrheic dermatitis, systemic lupus erythematosus or dermatomyositisHyperpigmentation related to the prior use of hydroquinone-containing productsI 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 NameLast Name
Date of Signature*

DayMonthYear
Date
Customer Signature*

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Skin Care Professional

First NameLast Name
Skin Care Professional: Date of Signature*

DayMonthYear
Date
Skin Care Professional Signature *

Clear
Should be Empty:

Fire & Ice Consultation Form

HEALTH

CONSENT FORM