Consultation form

Email: *

Are you taking any medication at the moment? If so, what?

Have you had any other aesthetic treatment such as Dermal Roller, Dermaplaning, or semi-permanent makeup? If so, when?

Parental Co-Sign (if under 16)

Address

Have you had Botox / dermal fillers? If so, when?

Minor contraindications (tick any that apply)

Eye infections

Skin disorders e.g Active acne, Seborrheic, Dermatitis

Herpes Simplex (cold sores) Eczema, Psoriasis, Rosacea

Keloid scars

Talangiectasia (broken capillaries)

Raised moles, Watrs, Skin tags

Cuts, Bruises, Abrasions

I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. I have been advised: No AHA's, Glycolics, Retinol, Anti-Ageing products or exfoliating products for 72 hours. No sauna, sun bed or sun exposure for 48 hours. No swimming, facial waxing, electrolysis or fake tan application for 24 hours. No heavy makeup for 12 hours. Use of SPF15 at all times during the course of treatment is strongly recommended. PLEASE READ CAREFULLY AND ONLY SIGN IF YOU ARE IN FULL AGREEMENT WITH ITS CONTENTS. I CONFIRM THAT I HAVE UNDERSTOOD THE TREATMENT THAT I AM ABOUT TO RECEIVE AND CONFIRM THAT I AM WILLING TO PROCEED WITHOUT CONFIRMATION FROM MY OWN GP OR CONSULTANT. *

Date of birth *

Doctors name/address

Date and time *

Phone *

Name: *