Client Consultaion Form
Name
*
First Name
Last Name
Email
*
example@example.com
Are you pregnant?
*
Please Select
No
Yes
N/A
Are you lactating?
*
Please Select
No
Yes
N/A
Do you have regular menstrual cycles?
*
Please Select
No
Yes
N/A
Do you suffer with Polycystic Ovary Syndrome?
*
Please Select
No
Yes
N/A
Have you ever had a Microneedle treatment before?
*
Please Select
No
Yes
If yes to the above what size needle?
Please Select
(10.20mm)
(0.25mm)
(0.30mm)
(0.50mm)
10.75mm)
(1.00mm)
(1.50mm)
12.00mm)
(2.50mm)
(3.00mml)
Do you have any allergies to local anaesthetics?
*
Please Select
No
Yes
N/A
Do you have any allergies to any metals?
*
Please Select
No
Yes
N/A
Do you have any other allergies, including aspirin?
*
Please Select
No
Yes
N/A
Have you ever used (or using) Roaccutane/Isotretinoin?
*
Please Select
No
Yes
N/A
Have you ever used (or using) Retin A?
*
Please Select
No
Yes
N/A
Do you have keloid scar or hypertrophic scar formation?
*
Please Select
No
Yes
N/A
Do you suffer with shingles?
*
Please Select
No
Yes
N/A
Do you suffer or have herpes (Cold sores)?
*
Please Select
No
Yes
N/A
Do you have any skin infections?
*
Please Select
No
Yes
N/A
Do you have cancer/or had cancer?
*
Please Select
No
Yes
N/A
Do you suffer from diabetes?
*
Please Select
No
Yes
N/A
Do you have kidney disease?
*
Please Select
No
Yes
N/A
Do you have a Thyroid Hormone condition?
*
Please Select
No
Yes
N/A
Do you suffer with Psoriasis/Eczema/Dermatitis?
*
Please Select
No
Yes
N/A
Are you taking any medication/Natural Remedies, including blood thinning medications?
*
Please Select
No
Yes
N/A
Are you being treated for any other condition?
*
Have you any tattoos or permanent makeup in the area to be treated?
*
Please Select
No
Yes
N/A
Have you had laser/Chemical Peels in the last 6 months?
*
Please Select
No
Yes
N/A
Are you currently undertaking any other treatments in clinic, including injectables?
*
Please Select
No
Yes
N/A
If yes to the above, please specify...
Are you currently using any AHA or Hydroquinone (skin lightening products)?
*
Please Select
No
Yes
N/A
Do you suffer from high blood pressure?
*
Please Select
No
Yes
N/A
Have you been sunbathing (real or sunbed) or used a 'self-tan' in the last week?
*
Please Select
No
Yes
N/A
How does your skin respond to sun exposure?
*
Please Select
Burn
Usually burn
Sometimes
Rarely burn
Never burn
What is your skin type
Normal
Oily
Combination
Sensitive
Other
What are your skin concerns?
Acne
Dry/Dull
Eczema
Fine lines & wrinkles
Hyperpigmentation
Oily skin
Sun damage
Scarring
Unwanted facial hair
Sensitivity
Rosacea
Blackheads
Drak circles
Large open pores
Discolouration
Puffy eyes
What is your current relationship with skincare?
I love trying different products all the time
I have a routine that works for me
I don't feel like my products are giving me results
I don't know what I should be using
Submit
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