Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Mobile Number
*
-
Area Code
Phone Number
Email address
*
example@example.com
Section 2: Skin Health & Current Concerns
What are your main skin concerns?
*
Fine lines / wrinkles
Skin laxity
Pigmentation / uneven skin tone
Redness / rosacea
Acne / breakouts
Acne scarring
Sensitive / reactive skin
Dryness / dehydration
Enlarged Pores
Uneven texture
Dull skin
Facial thread veins
Dark circles / tired looking eyes
General skin rejuvenation
Prevention / healthy ageing
Unsure / would like guidance
Other
How would you describe your skin?
*
Dry
Oily
Combination
Normal
Sensitive / reactive
Unsure
How does your skin usually respond to sun exposure?
*
Always burns, never tans
Usually burns, tans minimally
Sometimes burns, gradually tans
Rarely burns, tans easily
Very rarely burns
Deeply pigmented skin
Does your skin regularly experience any of the following?
*
Redness
Flushing
Burning / stinging
Breakouts
Dryness
Tightness
Easy irritation
Pigmentation after spots or procedures
None of the above
Type a question
*
Cleanser
Moisturiser
SPF
Vitamin C / antioxidant
Retinol / retinoid
AHA / BHA / exfoliating acids
Prescription skincare
Acne treatment
Pigmentation treatment
Growth factors / exosomes
Soap and water only
None
Unsure
Please list the main skincare products or brands you currently use.
Have you ever used a skincare product that caused a significant adverse reaction?
*
Yes
No
If yes, please provide details of the product and reaction.
Have you used retinol, prescription retinoids, glycolic/lactic/mandelic acid (AHA) / salicylic acid (BHA) or other exfoliating skincare within the last 7 days?
*
Yes
No
Unsure
If yes / unsure please tell us what you used and when you last applied it.
Have you taken isotretinoin (Roaccutane) within the last 6 months?
*
Yes
No
Unsure
If yes, when did you last take isotretinoin / Roaccutane?
Section 3: Skin Treatment Safety & Relevant History
Do you currently have any active skin infection, open wound, broken skin or significant inflammation in the area you would like treated?
*
Yes
No
If Yes. Please provide details
Have you ever had cold sores (herpes simplex)?
*
Yes
No
If Yes, when was your most recent cold sore, and how frequently do you tend to get them?
Have you ever been diagnosed with or treated for skin cancer?
*
Yes
No
If yes, please provide details, including the type of skin cancer and when it was treated.
Do you have any new, unexplained or undiagnosed skin lesion in the area you would like assessed or treated?
*
Yes
No
Unsure
If yes or unsure, please provide details.
Are you currently under the care of a dermatologist, oncologist or other medical specialist for a skin-related condition?
*
Yes
No
If yes, please provide details.
Have you had any of the following treatments in the last 2 weeks?
Chemical peel
Laser / IPL
Radiofrequency treatment
Microneedling
Microdermabrasion
Dermal filler
Anti-wrinkle injections
Waxing / threading / depilatory treatment
Other
None of the above
Other
Please provide details, including the treatment and date.
Have you had significant recent sun exposure, used a sunbed, or are you planning significant sun exposure within the next 2 weeks?
Yes
No
Are you currently pregnant, breastfeeding, undergoing IVF or trying to conceive?
*
Yes
No
Not applicable
If yes, please provide details.
Are you currently using any prescription creams, topical antibiotics, topical steroids or prescription retinoids on the area you would like treated?
*
Yes
No
Unsure
If yes, please provide the name of the treatment and what you are using it for.
Do you have any known allergies or sensitivities relevant to skincare or skin treatment, including aspirin / salicylates?
*
Yes
No
If yes, please provide details, including the reaction you experience.
Have you shaved the area you would like treated within the last 24 hours?
*
Yes
No
Not applicable
Do you have any semi-permanent makeup, permanent makeup or tattooing in the area you would like treated?
*
Yes
No
Not applicable
If yes, please provide details and the area involved.
Do you wear contact lenses?
*
Yes
No
Is there anything else about your skin, health, medications or previous treatments that you think may be relevant to your skin assessment or treatment?
Section 4: Declaration
Please confirm:
*
I confirm that the information I have provided is accurate and complete to the best of my knowledge.
I understand that I must inform ReNu Medical Aesthetics of any changes to my health, medications, skincare or circumstances before treatment.
I understand that completing this questionnaire does not constitute consent to treatment.
I understand that any proposed treatment, expected benefits, risks, alternatives and aftercare will be discussed with me and treatment-specific consent obtained separately before treatment.
Electronic signature
*
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Should be Empty: