Treatment Form

Full Name* This field is required.

First Name

Last Name

Address* This field is required.

Street Address

Street Address Line 2

Town/ City

County

Postcode

Country

Contact Number* This field is required.

Date of Birth* This field is required.

E-mail* This field is required.

Preferred method of contact* This field is required.

What are your skin goals? * This field is required.

What are your skin concerns?* This field is required.

Fine lines and wrinkles

Enlarged pores

Blackheads and congestion

Acne

Hyperpigmentation

Sun damage

Dull, tired looking skin

Hormonal breakouts

Dry and flaky skin

Excess oil

Rosacea / Redness / Sensitivity

Other

What products do you regularly use as part of your skincare routine?

Cleanser

Toner

Moisturiser

Actives (Retinal, Vitamin C etc)

Acids (Hyaluronic Acid, Salicylic Acid, Glycolic Acid etc)

Sunscreen

Exfoliates (scrubs, gloves etc)

Hydration masks

Eye creams

Do you have any allergies or have you experienced an allergic reaction to medicine or products (such as latex, plaster, nickel etc)?* This field is required.

YESNO

Do you have or are you having injectables, fillers or chemical peels?* This field is required.

YESNO

Do you have any imminent holiday plans?* This field is required.

YESNO

Do you have any keloid scarring?* This field is required.

YESNO

Do you suffer from epilepsy and have had a seizure in the last 2 years?* This field is required.

YESNO

Do you suffer from Haemophilia?* This field is required.

YESNO

Do you knowingly have any infectious diseases?* This field is required.

YESNO

Do you knowingly have Hepatitis C?* This field is required.

YESNO

Do you suffer from cold sores, fever blisters or skin disorders in the area to be treated?* This field is required.

YESNO

Do you have diabetes?* This field is required.

YESNO

Do you have any respiratory problems?* This field is required.

YESNO

Do you suffer from or have any problems with wound healing?* This field is required.

YESNO

Do you take bloody thinners or anti- inflammatories?* This field is required.

YESNO

Do you take Roaccutane?* This field is required.

YESNO

Do you have high or low blood pressure?* This field is required.

YESNO

Do you wear contact lenses or suffer from glaucoma?* This field is required.

YESNO

Are you currently taking any medication?* This field is required.

YESNO

If yes, please list below. Otherwise leave blank

Signature* This field is required.I have read and understood this section

Clear

I understand the importance of providing an accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.* This field is required.

YESNO

Signature* This field is required.I certify that i have read and i have had explained to me, and fully understand to above consent form and that i have requested to have permanent cosmetic enhancement of my own free will.

Clear

Date* This field is required.

Date

Would you prefer a silent facial? Please don’t think I’ll be offended if you say yes, i want you to get the most out of your facial treatment.

YESNO

Treatment Form