Dermaplaning consultation-Kilkenny Beauty and Laser Clinic

Dermaplaning consultation
Therapists Name if known

First NameLast Name
Date of appointment

MonthDayYear
Date
Clients Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Eircode
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
What are your main skin concerns
List the skincare products you are using and how often you use them
Cleanser: Type
Toner:Type
Moisturiser: Type
Eye Cream/Gel: Type a label
Serum:  Type a label
Exfoliator: Type a label
Do you use daily Sun protection factor  Type yes or no
If yes list product and factor Type a label
Are you taking any skin supplements?  Type a label
Have you had any issues with your skin in the past?  Type a label
Do you or have you ever used sunbeds
If you answered yes to the above question when was the last time you used a sunbed blanks
Have you recently used Self tanning lotions or creams

YesNo
Have you Ever had/Do you have any of the following

CancerHepatitiscontagious or infectious diseasesSkin DiseasesUndiagnosed lumps and bumpsLocalised swellingHypersensitive skinInflammationscar tissueHaematomaSunburnWindburnRecent fracturesHerpes or skin infectionsLoss of skin sensationCardio conditionsRecent surgeriesEczemaDepressionTaking prescribed medicationPsoriasisEpilepsyDiabetesAlready being treated by a GP or medical practitionerPregnantThyroid medication or thyroid imbalanceNoneTopical medication
If you ticked any of the conditions above give details blanks .
Are you currently being treated for a condition not listed blanks If so what blank
Are you prone to keloid scarring
Are you allergic to any of the following
Have you ever had any of the following facial treatments

IPL in the last 4 weeksLaser in the last 4 weeksMicroneedlingNoneRecent waxing or depilitory treatmentOther
Do you have any of the following

BotoxFillerspermanent make upTattooHerpes simplexCosmetic injections
Have you ever had a reaction to a treatment
Do You or have you used any of the following

RetinolRetin ARoaccutaneGlycolic peels in the last 14 daysAccutaneAHA in the last 14 daysOther peeling agent in the last 14 daysNone
If you ticked any of the boxes above please give details blanks
Are you currently or have you in the last 3 years taken any of the following

Blood Thinner or AspirinAnti coagulant medicationAnti platelet drugsSteroidsImmunosuppressive DrugsOther MedicationNoneOther
If You have ticked any of the above please give details here blanks
Female Clients only:Are you currently

Taking HRTTaking ContraceptionHaving menopausal ProblemsOr recently made changes to contraception
If you ticked any of above please give details blanks
What are your expectations from this treatment
Tick below to agree to the following

I confirm that I understand the treatment its risks, benefits, adverse reactions, contra indications and am happy to proceed. I have disclosed anything that may affect the treatment including medications, products used, previous treatments and allergies that may affect this treatment. I understand that treatment involves a sterile blade and as with the use of any sharp instrument, it may result in nicks or cuts. Although every precaution is taken during treatment there are still risks.
Tick to agree to the following

I agree to Kilkenny Beauty and Laser Clinic using my details for the purposes of this treatment
Tick to agree to the following

I have answered all questions
Tick to agree to the following

I agree to Kilkenny Beauty and Laser Clinic using my information for special offers and updates
I have been informed about the expected results and expected after effects of treatment.I agree to follow all aftercare which has been given to me by my Therapist. Signature

Clear
Date

MonthDayYear
Date
To be filled by your therapist-Skin analysis

melasmaacne/acne scarringBlack headsMiliaCysts/nodulesAge spotsDehydrated skinRosaceaSundamage
Any other notes
Consultation checked and Precare/Aftercare supplied to client. To be signed by your Therapist:

Clear
Julie Burke
Should be Empty:

Dermaplaning consultation

Julie Burke