Name
Address
Phone number
-
Area Code
Phone Number
Email address
example@example.com
I am currently using or have used Accutane (isotretinoin) in the last six months
Yes
No
I am pregnant or nursing/lactating
Yes
No
I have allergies
Yes
No
I have a skin infection/open wound in the treatment area
Yes
No
I am allergic to aspirin (acetylsalicylic acid)
Yes
No
I have been exposed to the sun or used a tanning bed in the last 3 weeks
Yes
No
I am currently using sunless tanning products
Yes
No
I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
Yes
No
I have used skincare products that caused an adverse reaction
Yes
No
If you answered YES to any of these, please explain further
Do you have any medical issues?
What is the main reason for your inquiry today?
Have you had a facial or peel treatment before?
Yes
No
When I think about my appearance, I feel | look- Please pick three
Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive
On a scale of 1 to 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skins appearance?
After treatment I would like to feel-Please tick three
Fresher
Happier
Brighter
More awake
More youthful
More illuminous
More confident
What are your main skin concerns?
When did you first notice your concern?
Which of these apply to your skin?
Lines (superficial)
Wrinkles
Decreased volume
Loss of elasticity (saggy skin)
Dryness
Blackheads
Whiteheads
Cysts (boils)
Acne Scarring
Sallow (yellow/dull) complexion
Oiliness
Open pores
Hyperpigmentation (brown spots)
Hypopigmentation (white spots)
Uneven skintone
Freckles
Broken capillaries
Inflammation
Redness
Sensitivity
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine?
Are there any specific products you would like to try?
Which of these in-clinic treatments interest you?
Chemical Peels
Microdermabrasion
Facials
Dermaplaning
LED Light Thrapy
Micro-needling
Waxing
How did you hear about us?
Referral
Search engine
Social media
Other
Preferred contact details
Phone:
Email:
Address
Signature
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