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Facial Consultation Form

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This form should be completed prior to your first appointment, when it has been longer than 6 months between appointments or when there has been a significant change to your medical history or lifestyle that could impact upon your facial treatments. 

Client Contact Details

Age
Teen
20-30
31-40
41-50
51-60
61+

Emergency Contact Details

Medical Details

Have you been under medical care in the last 6 months?
Yes
No
Have you undergone surgery within the last 6 months?
Yes
No
Do you suffer with any neck or spinal injuries?
Yes
No

Lifestyle

Rate your stress level with 1 being the lowest and 5 being the highest
1
2
3
4
5
Is your sleep disturbed?
Yes
No
Do you smoke?
Yes
No
Do you exercise regularly?
Yes
No
Do you follow a restricted diet?
Yes
No
Do you use sunbeds or sunbathe?
Yes
No

Hormones

Are you currently ... (please tick all that apply)

Skin Concerns

Have you ever had a skin reaction?
Yes
No
Do you ever experience sinus problems?
Yes
No
Have you ever experienced any stinging sensation of the skin?
Yes
No
Do you experience any redness?
Yes
No
Do you experience flushing and blushing?
Yes
No
Do you experience flakiness and tightness?
Yes
No
Do you experience an oily shine?
Yes
No
Do you experience breakouts?
Yes
No

Exfoliation / Advanced Treatments

Do any of your products contain resurfacing ingredients such as Vitamin A / Retinol / Retain A / Hydroxy Acids (AHAs and BHAs) / Fruit Enzymes?
Yes
No
Within the last 6 months have you had any medically prescribed acne products e.g. Roaccutane / Retinol / Retain A / Retinova / Tarozac / Other?
Yes
No
Have you ever experienced a chemical peel?
Yes
No
Have you had a resurfacing treatment within the last 6 months?
Yes
No
Have you had any advanced treatments such as Microneedling / Botox / Fillers within the last 3 months?
Yes
No

Images

Please indicate your consent to use your images for the purposes of marketing and literature:
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