Facials form | Laser Treatments

First name

Last name

Email

Address

Birthday

Day

Month

Year

Phone

Holidays / Recent UV exposure

Contra-indications – (Select if/where appropriate):

Are you trying to conceive?

Are you pregnant?

Are you lactating?

Are you on HRT / Contraception?

Are you using/applying prescribed medication?

Are you using steroidal medication (topical)?

Are you using Retinoic Acid/Retin A /Ro-Accutane?

Are you on any blood thinning medication?

Are you currently taking antibiotics?

Are you using a photosensitising medication?

Are you taking St John’s Wort?

Have you had recent radiation treatment?

Do you have any burns?

Do you have immunosuppression?

Have you had recent operations on the area you want treating?

Do you suffer from active infections either bacterial, fungal, herpetic, viral?

Do you suffer from psoriasis?

Have you suffered from skin cancer/ basal cell carcinoma/squamous cell carcinoma/ melanoma?

Do you have currently active inflammatory dermatoses?

Do you suffer from Atopic dermatitis?

Do you suffer from any blood disorders (HIV, Hepatitis)?

Do you suffer from keloid scarring?

Do you suffer from hypertrophic scaring?

Do you have sunburn?

Have you used fake tan within last 14 days?

Do you have diabetes?

Do you have kidney disease?

Do you suffer from medical oedema?

Do you have any tattoos or moles in the treatment area?

Do you suffer from impaired healing?

Are you gluten intolerant?

Do you have any allergies to salicylic acid?

Do you have excessive/deep skin folds?

Are you lactose intolerant?

Do you have any other allergies?

Have you had Covid?

None of the above

If answered any as Yes, please give details

Contra-indications that restrict the procedure – (Select if/where appropriate):

More information

Contra-indications requiring medical referral – in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to the procedure

Comments

Have you had any health problems in the past or present?

Have you been under the care of a medical practitioner or other healthcare specialist in the last year?

Are you currently using any prescription medications (oral or topical)?

Are you currently using any supplements or herbal remedies (oral or topical)?

Do you suffer from anxiety, stress, depression and/or are clinically diagnosed?

What are your stress levels? 1 to 10 (10 being the highest)

Do you drink alcohol?

Do you wear a sun protectant?

Do you suffer from Herpes simplex?

Are you allergic to any of the following? (please tick all that apply)

Comments if any answers were YES

Do you use home care products containing any of the following?

Exfoliating granules

Glycolic Acid

Lactic Acid

Other Alpha/Beta Hydroxy Acids

Vitamin A derivatives (Retinol)

None

Comments if any answers were YES

What is your current daily skincare regime, including product details?

What specific skin concerns do you have?

What are your expectations of this procedure?

I have provided accurate medical information and consultation details to my advanced aesthetic practitioner.

I do not have any active Herpes simplex (cold sores). Prophylactic antiviral medication or topical antiviral cream may be used up to 2 days before and up to 3 days after the procedure.

I agree not to receive any of the following on the procedures area 2 weeks prior to the procedure – Botox, injectable dermal fillers or chemical peel/microneedling procedures.

I agree not to receive any of the following on the procedure area 2 weeks prior to the procedure – bleaching, electrolysis, depilation, facial treatments using AHA/BHA/Vitamin A, hair colouring, IPL/Laser for skin rejuvenation, IPL/Laser for hair removal, light therapy, microdermabrasion

I agree to avoid the use of any prescribed topical medications i.e. Retin A, Salicylic Acid a minimum of 2 weeks prior to the procedure.

I confirm that I have not used Isotretinoin in the past 6 months.

I agree to avoid the use of active skin care 3-5 days prior to the procedure.

I agree to avoid direct sun exposure.I agree to apply a sunscreen daily (minimum SPF30).I agree to avoid fake tanning preparations a minimum of 10 days prior to the procedure.

I agree to avoid heat treatment immediately prior and after the procedure.

I understand that the following contra-actions may occur:

· Acne breakouts

· Excessive flaking

· Blanching

· Frosting

· Hypopigmentation

· Hyperpigmentation

· Discomfort

· Itching/irritation

· Scarring

· Excessive erythema (redness)

· Infection

I understand that procedure results are varied and not guaranteed.

I have discussed my expectations and goals with my advanced aesthetic practitioner.

I acknowledge the possibility of an adverse reaction to procedure and take sole responsibility for any medical care that may become necessary. I agree to immediately contact the advanced aesthetic practitioner performing the procedure of any adverse effects.

My advanced aesthetic practitioner has provided the procedure information and answered all of the questions I have concerning this procedure.

I fully understand all of the above information.

I understand that consultation cost is £25 (This can be used as credit for first full price procedure if consultation is attended). Any last minute cancellations will incur a charge of £25.

Patient Signature

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Practitioners signature

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Practitioner's notes

CONSULTATION FORM - Facials / Chemical Peels / Microneedling