CONSENT FORMS

CONSULTATION FORM

NAME 
ADDRESS   
DOB 
EMAIL 
OCCPUATION 
DRS NAME/ ADDRESS   
PLEASE TICK THE RELEVENT BOXES AND COMMENT FURTHER IF NEEDEDYESNO
Do you currently suffer from or have suffered previously from any skin disease? If yes provide information
Do you have any allergies? If yes provide information
Are you allergic to stainless steel/ nickel?
Do you currently have or have you in the past suffered from any skin irritation? If yes provide information
Do you have sensitive skin, or a history of reactions to topical skincare products? If yes provide information  
PLEASE TICK THE RELEVENT BOXES AND COMMENT FURTHER IF NEEDEDYESNO
Do you suffer from cold sores?  
Do you suffer from any autoimmune diseases? If yes provide information  
Are you an insulin diabetic?  
Do you have active shingles?  
Are you haemophiliac?  
Are you taking any blood thinning medication?  
Are you taking any medication for acne? If yes provide information  
Do you suffer from eczema/ psoriasis  
Do you suffer from acne?  
Do you have any scar tissue on your face / neck which is >3 months old?  
Are you taking any prescription medication?  
PLEASE TICK THE RELEVENT BOXES AND COMMENT FURTHER IF NEEDEDYESNO
Are you taking oral contraceptives or other hormones?  If yes provide information    
Do you regularly spend time outdoors (e.g golf, tennis, cycling, gardening etc)?  
Have you had any topical treatments with glycolic acid or retinoids (eg tretinoin, retinol or vitamin A acid derivatives) in the last month? If yes provide information    
Have you ever had any kind of dermabrasion treatment or a chemical peel? If yes how long ago? Did you have any problems with that therapy?    
Do you shave, use hair removal products or wax in the affected area?  
What skincare do you currently use?  
Do you wear make-up? If yes, what?   How do you find make-up looks on your skin?  
PLEASE TICK TO CONFIRMCONFIRMATION
I confirm that I am not pregnant or breastfeeding We advise you do not have a peel when pregnant
I do not have any allergies 
I have not had microdermabrasion in the last 7 days 
I have not exfoliated in the last 7 days Exfoliating in the last 24 hours may lead to increased irritation 
My skin is not hypersensitive 
What is the purpose of this treatment:
Photo ageing/ sun damage                     Acne             Pigmentation             Exfoliation          Fine lines & wrinkles                     Pore size                   Skin tone                       Melasma               Acne scars                    Vellus hair removal                Rough/ dry skin             Smoother skin    Other ………………………

AFTERCARE ADVICE

  • Use sun protection during the day regardless of the weather
  • Do not have any other facial treatments whilst undergoing your treatment course
  • Do not use any exfoliating products for at least 1 week after the final professional treatment

DECLARATION

Client declaration: I confirm to the best of my knowledge that answers that I have given are correct and I have not withheld any information that may be relevant to my treatment. I have read all of the above and have been given advice from my therapist. I accept responsibility for the decision n to have this treatment.

Signed………………………………………………………………………..Date………………………………………………….

Therapist Sign……………………………………………………………..Date…………………………………………………..

FOLLOWING TREATMENTS:

I confirm that the above information is all correct since my last treatment.

Date……………………………………… Client Sign…………………………………………………………………………………..

Date……………………………………… Client Sign…………………………………………………………………………………..

Date……………………………………… Client Sign…………………………………………………………………………………..

Date……………………………………… Client Sign…………………………………………………………………………………..

Date……………………………………… Client Sign…………………………………………………………………………………..