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Welcome to your bespoke consultation form. Completing this form accurately is essential for your treatment, so please provide detailed responses to ensure we achieve the best possible results for you and your skin.

Date of Birth
How did you hear about us?
Treatwell
Google search
Friend/Family
Social Media
Other
What treatment are you booked in for?
Hydradermabrasion
Dermaplaning Deluxe
Acne Facial
Pregnancy Facial
Earth, Wind & Fire Facial
Deep Cleansing Facial
Other
What are your primary skin concerns? (Please select all that apply)
Do you have any of the following conditions
Are you currently pregnant/breast feeding?
Yes
No
Are you currently taking any medications or undergoing any medical treatments that may affect your skin?
Yes
No
Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
Do you have a predisposition to keloid or hypertrophic scars?
Yes
No
Have you had electrolysis, depilatory creams, or waxing on the area to be treated in the last week?
Yes
No
Do you have any of the following contraindications?
How would you describe your skin type (Please refer to the fitzpatrik scale)
Light white/pale (always burns, never tans)
White/fair (tan with difficulty)
Medium/white to olive (gradually tan to olive)
Olive (rarely burns and turns to medium brown when tanning)
Brown, dark brown (rarely burns and tans easily)
Black, very dark brown to black (never burns, deeply pigmented)
How would you describe your daily lifestyle?
How often do you exercise?

In some of our facials we like to include a complimentary neck, shoulder and head massage. Please select below whether you would like for it to be included or would prefer to opt out.

Would you like to us to include massaged?
Yes
No
If yes, what level of pressure do you prefer?
What treatment vibes do you prefer?

I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction.


Development of any reactions must be reported to the practitioner as soon as possible. I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.


I may require a series of treatments, normally with at least 2-4 weeks between procedures, to achieve the maximum cosmetic result.

I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.

I also consent (please tick as applicable) to these photographs being used for
Date
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