Please enable JavaScript in your browser to complete this form.Consultation FormPatient name *Address *Address Line 1Address Line 2CityState / Province / RegionPhone *Email *Age Group *Under 2020-2930-3940-4950-5960+OccupationLifestyle *Active SedentaryDetails of activityGP Name & Address *HealthContra-indications that prevent treatment Active acneBlood borne diseasesHaemophiliaOpen wound(s)RosaceaImmunosuppressive therapy (MS, Lupus, RA)Allergy to surgical grade stainless steelContagious skin diseasesInflammation/swellingPhotosensitising medicationSkin cancerCardiac abnormalitiesAnticoagulant/steroid medicationHypersensitive skinIsotretinoin use in the last 6 monthsRecent scar tissueUndiagnosed lumpsCollagen vascular diseases/schlerodermaPlease check any that apply to youCommentsContra-indications that restrict treatmentAbrasionsActive inflammatory dermatosesAnxietyBotox/dermal fillersBruises/raised molesCurrent medicationsCutsDirect sun exposure in last 24 hoursDiabetesEpilation treatmentEpilepsyFeverHerbal remediesHerpes simplexHistory of hypertrophic/keloid scarringHypersensitive skinIPL treatmentLaser treatmentLarge molesLong-term anti-inflammatory usePiercingsPoor mental/emotional statePrior to cosmetic surgeryRecent microdermabrasionRecent chemical peelReactive skin typeSupplementsVaricose veinsEczema/Psoriasis/DermatitisOther?Please check any that apply to youCommentsHave you ever had any health problems in the past or present?YesNoHave you been under the care of a medical practitioner or other healthcare specialist in the last year?YesNo Are you currently using any prescription medications (oral or topical)?YesNoAre you currently using any supplements or herbal remedies (oral or topical)?YesNoDo you suffer from anxiety, stress, depression and/or are clinically diagnosed?YesNoWhat are your stress levels at work? Selected Value: 1 1 to 10 (10 being the highest)What are your stress levels at home? Selected Value: 1 1 to 10 (10 being the highest)CommentsDo you smoke? Have you smoked in the past/present?YesNoIf yes, how much?Do you drink alcohol?YesNoIf yes, how much?Are you trying to conceive, pregnant or lactating?YesNoAre youDue or having your menstrual periodPeri-menopausalMenopausal Do you have any allergies?YesNo Are you currently sun/wind burnt?YesNo Do you wear a sun protectant?YesNoDo you suffer from Herpes simplex?YesNoYour SkinHave you had any of the following within the last 1-4 weeks?Botox/injectable dermal fillersDepilatory treatmentsElectrolysisFacial surgeryIPLRetin ALight based therapyLaserMicrodermabrasionSkin needlingSkin peelingPrescription skincare productsPlease check all that apply to youIf yes to any of these, please specify treatment details (treatment dates, frequency of treatment, results and client satisfaction with outcome)Have you used any home care products containing any of the following in the last 3 days?Exfoliating granulesGlycolic AcidLactic AcidOther Alpha Hydroxy AcidsVitamin A derivatives (Retinol)Please check all that apply to youIf yes, please specify skin reaction after use:Your Skin RoutineWhat is your current daily skincare regime, including product detailsMorning EveningWhat specific skin concerns do you have?What are your expectations of this treatment?Skin AssessmentSkin typeNormalCombinationDryOilySensitiveSkin conditionSensitiveDehydratedMatureTelangiectasiaPapulesOpen PoresDark circlesPigmentionScarringErythemaMaculesPustulesCheck all that applySkin healing capacityBrown pigmentationPink/fades to whiteScarring history/detailSkin thicknessThinMediumThickUpload a photo of your face/skin Click or drag a file to this area to upload. Treatment objectiveReduction in fine linesImprovement in skin conditionImprovement in skin textureImprovement in skin laxityImprovement in stretch marksI fully understand all of the above informationYes, I fully understandNo I don't understandSignaturePlease print your full nameSubmit
