Treatment Intake FormConsultation & Consent FormPlease enable JavaScript in your browser to complete this form.Name *Address *Address Line 1CityState / Province / RegionPostal CodePhone *Emergency Contact *Email *Date of BirthDo you take, or use any products that contain the following? *Retinoid (e.g Tretinoin, Retin A, Retinol, Retinoic Acid, Retinal)Second Any treatment for acne (e.g. Accutane, Adapalene, Differin etc.)Any treatment for scarring or pigmentation (e.g. Hydroquinone)Topical steroidsBenzoyl PeroxideAHA/BHA (e.g. Glycolic, Lactic, Salicylic etc.)Oral or Topical AntibioticsSocial Media Image Consent *YesNoDo any of the following statements apply to you? *I have had recent surgery or cosmetic procedure/sI have recently undertaken facial waxing treatment/sI have had recent cosmetic injectable treatment/sI have had recent dermabrasion, chemical/glycolic peel/sI have had skin cancer or skin cancer removalI have had recent accidents, injuries or fallsI am/could be pregnantI am breastfeedingI have undiagnosed lumps, swelling, or painI have allergiesPlease give details:Please tick if any of the following apply to you: *DiabetesEpilepsyCancerHaemophiliaMedical oedemaJoint replacementClaustrophobiaVertigoCirculation problemsSkin conditionsMigraine/headachesSprainsAsthmaAny skeletal conditions (e.g. arthritis, osteoporosis, bursitis, postural deformity, spondylosis, herniated disc etc.)Any muscular conditions (e.g. fibromyalgia, lumbar, tendonitis etc.)Any cardiovascular conditions (e.g. thrombosis, phlebitis, hypertension, hypotension, heart conditions etc.)Any dysfunction of the nervous system (e.g. multiple sclerosis, parkinson's disease, motor neurone disease etc.)Any other medical conditionPlease give details:Skin type *NormalDryOilyCombinationSensitiveSkin conditions or concerns *AcneFine LinesRough PatchesDehydrationEnlarged poresBlemishesWrinklesLoss of elasticityUneven skin toneHyperpigmentationRednessDullnessDark under eyesPuffinessTell me about your current home care routinePatient consent and declaration *I understand and agree to the statement belowI consent to the use of a numbing agent/topical anaesthetic if required.I understand the necessity of taking photos for insurance purposes.I acknowledge the cosmetic nature of the treatment.I understand the implications of publishing negative results online.I am aware of the clinic's operating hours for addressing complications.I understand the risks of new procedures and the practitioner's non-responsibility for product faults.I will not attend treatment if showing symptoms of COVID-19.I understand that in the unlikely event of an adverse reaction, my first point of contact is my practitionerWe will always encourage our clients to come in and see us for a review before seeking alternative advice. In the majority of cases, we will be able to resolve your problems in-house. We advise that you do not book in with another company or clinic (except your GP/HOSPITAL) as this immediately invalidates our review procedure and your insurance policy. If you are concerned for your immediate health please go straight to your GP or A&E.e-Signature *I hereby affirm that the health information provided in this form is accurate and complete to the best of my knowledge. I understand that this information is crucial for safely and effectively customising my skincare treatments. I acknowledge that withholding or providing inaccurate health information can lead to adverse reactions or ineffective treatment. I consent to the use of my health and personal data for the purpose of designing and administering skincare treatments. I understand that this information will be treated with confidentiality and will be used exclusively for my treatment planning and follow-up care. By typing my name in the box above, I acknowledge that it constitutes my electronic signature, which holds the same legal effect and enforceability as a handwritten signature. I also acknowledge that I have read and understood the information about the skincare treatments offered and the potential risks and benefits associated with them. I agree to proceed with the treatments based on this understanding.Submit
