Consultation Card for facials
Please fill out the following health declaration form in order to book a treatment with me. Submissions has to be done prior your booking. Thank you for taking your time to do that. I will check and get in touch, if there are any concerns. Looking forward pampering you soon.
I agree to inform immediately, if my body temperature is getting higher than 37°C, develop cough or loose my sense of taste and smell in the last 24 hrs prior to the treatment.
Heart Condition
Yes
No
If YES, elaborate more
High or low blood pressure
Yes
No
If YES, elaborate more
Diabetes
Yes
No
If YES, elaborate more
Cancer
Yes
No
If YES, elaborate more
Have you ever used acne medication?
Yes
No
If YES, elaborate more
Have you ever had chemical peels, laser or microdermabrasion?
Yes
No
If YES, elaborate more
Loss of skin sensation
Yes
No
If YES, elaborate more
Pregnancy
Yes
No
If YES, elaborate more
Epilepsy
Yes
No
If YES, elaborate more
Do you use Retin-A, Retinova, AHA or Retinol products?
Yes
No
If YES, elaborate more
Recent scars or surgeries (under 6 months)
Yes
No
If YES, elaborate more
Skin disorders
Yes
No
If YES, elaborate more
Medications
Yes
No
If YES, elaborate more
During hemotherapy or radiotherapy
Yes
No
If YES, elaborate more
What skin brand currently you are using?
What areas of concern do you have regarding our skin?
Breakouts/Acne
Blackheads/Whiteheads
Excessive Oil/Shine
Are you using some of the below:
Facial soap/Cleanser/Wipes
Toner
Daily Moisturiser
SPF
Night Cream
Serum
Eye Cream/gel
Scrub/Exfoliator/Mitts
Face mask
Allergies
Yes
No
If YES, elaborate
First Name
Last Name
Email
Phone Number
Address
Leave clear instructions for parking. We carry heavy equipment, so immediate free parking is required
Please upload a doctors notes, if you have medical condition and require adapting on your treatments
Select a File
I agree to the terms & conditions and I confirm that the information given in this form is true
Date
Your Signature
*
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