Consultation Form

Consultation Form

About You
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Email*
example@example.com
Contact Number*
Natural eye colour*
Natural hair colour*
Nationality*
Do you consider your skin (please tick all that apply)

SensitiveResilientUnsure
Do you suffer with any of the below (please tick all that apply)

Broken capillariesRosaceaEczemaPsoriasisAcne
Describe your skin (please tick all that aply)

NormalDryDullCombinationDehydratedOilyThickThinAcneLarge PoresSundamagedUnevenBlotchyFreckledBlocked poresHyperpigmentationHypopigmentationReddened
What are your top three main skin concerns?*
What changes do you most want to see in your skin?*
Do you wear makeup daily?*

YesNo
Do you cleanse daily?*

YesNo
Do you use an exfoliator?*

YesNo
If so, how often?
Do you use SPF daily?*

YesNo
Do you moisturise daily?*

YesNo
Do you take any skin supplements?*

YesNo
Do you use an eye product?*

YesNo
Are you currently using any products containing the below ingredients?

RetinolVitamin CSPFGlycolic AcidLactic AcidSalicylic Acid
Are you pregnant or breastfeeding?*

YesNo
Do you wear contact lenses?*

YesNo
Do you currently have a sunburned/ windburned/ red face?*

YesNo
Do you use sunbeds?*

YesNo
Have you exposed your face to direct sunlight (sunbathed) in the last month?*

YesNo
Are you planning on exposing your face to direct sunlight in the next month?*

YesNo
Do you practice vigorous exercise?*

YesNo
Have you had any facial waxing or threading in the past week?*

YesNo
Have you had any other facial treatment in the last 2 weeks? (Including chemical peels, dermaplaning, microneedling, PRP)*

YesNo
Have you had facial fillers or BOTOX injections in the past 2 weeks?*

YesNo
Have you had facial laser or another facial machine treatment in the last month? (Including HI FU and RF)*

YesNo
Are you currently taking any medication for your skin, topical or otherwise?*

YesNo
If yes, please give details. (Including Tretinoin, Retin-A, Differin, EpiDuo)
Have you ever undergone Roaccutane / Accutane therapy?*

YesNo
If yes, please give details.
Are you presently under physician's care for any current skin condition?*

YesNo
Are you allergic to nuts?*

YesNo
Are you allergic to Vitamin A*

YesNo
Are you allergic or sensitive to any of the following (please tick all that apply)

MilkApplesCitrusGrapesAspirinLatexAloe Vera
Do you suffer with cold sores? If yes, when did you last break out?*

YesNo
Have you ever had an allergic reaction to a skincare product?*

YesNo
If yes, please give details.
Prior to receiving trearment, I have been candid in revealing any condition that may have bearing on this procedure.

I understand there may be some degree of discomfort such as tingling, redness, heat or tightness.

I understand to achieve maximum reseults I may need several treatments.

I understand that the use of tanning beds or exposure to the sun is prohibited while I am undergoing treatment and during the 14 days prior to and following the end of treatment.

I understand I should follow my practitioners recommendations and advice post - procedure to minimise side effects and maximise results.

I hereby agree to all of the above and agree to have this treatment performed on me.
Signature
Date

MonthDayYear
Date
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