Name
*
First Name
Last Name
DOB
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Email
*
Emergency Contact Name
In the case of any emergency we may need to contact them.
First Name
Last Name
Emergency Contact Phone
How did you hear about us?
*
If other, please specify. If someone referred you please list their name and phone number so we can thank them
Please tell me a little bit about your concerns if you have any.
What are your skin + wellness goals?
*
What are your skin challenges?
*
Check all that applies to you
Have you ever had a facial or skin treatment before? When was your last treatment?
What skincare products are you currently using?
Do you / have you used Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other vitamin A derivatives
Please list any medications you are currently taking or have taken in the last 6 months, including herbal supplements
Have you received chemical peel, skin needling, laser, microdermabrasion or dermaplaning ?
Have you received any Botox, Juvederm or other dermal fillers in the last 5 months?
Are you currently under the care of a GP, specialist or other health practitioner?
If yes, please list their name and contact details.
Have you experienced any of these health conditions in the past or present?
If you have selected any of the above conditions, please provide further information
Check any of the following that apply to you
Do you take any of the following dietary supplements?
Any known allergies
Have you ever used or been prescribed medications (oral or topical) for acne?
If yes, please specify medication used, duration of treatment and the date it was last used
Do any of the following apply to you?
Are you pregnant or trying to become pregnant?
Are you menopausal or peri-menopausal? If so, please describe any symptoms that you are currently experiencing
Are you undergoing HRT (hormone replacement therapy)?
What is your daily water intake like?
How would describe your physical activity
Sedentary (sitting for long hours, studying, watching tv)
Light intensity (Housework, working at a standing workstation)
Moderate Intensity (Brisk walking, recreational swimming)
High Intensity (aerobics, jogging, competitive sports)
How would you describe your diet?
How many hours do you sleep during the night?
Do you consumer any of the following?
Please rate your stress level
low (1-3 out of 10)
medium (4-6 out of 10)
high (8-10 out of 10)
Do you suffer from
Your energy levels are
What self-care do you do to manage your situations?
Describe in a few words how you are feeling today
Would you like to learn more about natural ways to manage stess?
Some other therapies that we provide include mindfulness, meditation, essential oils/aromatherapy, sound healing, flower essence therapy and EFT (tapping).
Post Skin Treatment Care
*
All physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatments. If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30+. Sunscreen with minimum SPF 15+ should become part of your daily skincare regimen as skin can potentially become more sensitised to the sun as a result of treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturiser. Do not apply additional exfoliating ingredients or products the day of your service as over exfoliation can result in irritation or further sensitivity. Enzyme peels and other treatments such as chemical peels may result in skin flushing and redness or slight skin flaking and sensitivity for up to 48 to 72 hours post treatment. Do not peel, pick, rub or scratch your skin at any time. This can potentially cause damage and can compromise your results.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal ridden disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I received here are voluntary and I release the skincare professional from liability and assume full responsibility thereof.
