First and Last Name
*
Are you over 18?
*
yes
no
If you are not over 18, you will need written parental consent.
Yes, I understand
Are you pregnant or breast feeding?
*
Yes
No
Are you taking any medications?
*
Yes
No
List of medications (if any)
Have you taken accutane or tetracycline in the last year?
*
Yes
No
Do you have a history of Cancer?
*
Yes
No
Do you have a history of Keloid scarring?
*
yes
no
Do you have a history of cold sores?
*
yes
no
Skin Concerns
*
Rows
No Concern
Low Concern
Medium Concern
High Concern
Active Acne
Acne Scarring
Dark Spots / Pigmentation
Dry Skin
Aging Skin
Large Pores
Rosacea
Melasma
Fine Lines / Wrinkles
are there any other skin concerns not listed above that you may have? if so please list them below
Other Treatments in the last 4 weeks:
*
Laser
Other Facial
Waxing
Botox / filler
Other
None
If other, please specify
Other treatments of interest
*
Medical Grade Skin care
Lash Lift + Tint
Teeth Whitening
Hair Treatments
Glow On
Microneedling
Chemical Peel
Acne Facial
Microdermabrasion
Dermaplan
High Frequency
Deep Clean
Customized Facial
Eyelash Extensions
None
Due to specific skin compositions varying between persons, results can not be guaranteed.
*
I understand
I understand the potential risks and complications and have chosen to proceed with the treatment having considered the possibility of both known and unknown risks, complications, and limitations.
*
I understand
photos are taken to track your progress and when shared online, your name and identity will be kept confidential and is solely used for marketing material.
*
I consent
By signing below, I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
*
I understand
Which facial have you booked?
*
Please Select
Microneedling
Advanced Microneedling - Hello Collagen
Chemical Peel
Acne Killer
Dermaplan - Glow Getter
Anti Aging - Timeless Skin
Ultra Hydrating - Feeling Quenched
Deep Clean - Spick and Span
Basic Facial - The Staple
Mini Facial - On the Go
By signing below, I hereby consent to receiving the facial treatment outlined above and acknowledge and certify that I have read and fully understand the above consent.
*
I understand.
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
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