Cellstory Treatment

Cellstory Treatment

Client Consultation Form
Name*

First NameLast Name
Male/Female

FemaleMale
Age Group

Under 2020-3030-4040-5050-6060+
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Email*
example@example.com
Telephone No*
Contra-indication
Cancer (if a history of cancer, check with doctor)SunburnRoactutane (12 months since completing course)Surgery (at least 6 months post surgery)Active coldsoresRetin a ( 3 months after course is complete)Chronic inflammatory skin conditionsAny auto-immunes
Proceed with Caution
Botox (2 weeks before/2 weeks after)Chemical peel (2 weeks before/2 weeks after)Microdermabrasion (2 weeks before/2 weeks after)Waxing (1 week before/ 1 week after)Retional products (we advise to stop using these for 3 days before and 3 days after)Fillers (4 weeks before/4 weeks after)
Medical Information
PregnantNursingDiabetesHigh blood pressureHeart diseaseAutoimmune diseasesEpilepsy or seizuresAsthma
Allergies to Specific Ingredients or Products:
Recent Facial Surgeries or Treatments:
Other Medical Concerns:
Emergency Contact
Name*

First NameLast Name
Relationship
Telephone No*
Medical History

(to include medications)
Consent and Agreement
I understand that the facial treatment is not a substitute for medical treatment or advice. I have provided accurate
information to the best of my knowledge. I consent to the facial treatment and agree to follow the technician's
recommendations for aftercare and skincare
Client Signature*

Clear
Date

DayMonthYear
Date
Therapists Signature*

Clear
Date

DayMonthYear
Date
Should be Empty:

Cellstory Treatment

Contra-indication

Proceed with Caution

Medical Information

Emergency Contact

Medical History

Consent and Agreement