FULL NAME

Date of Birth (DD/MM/YYYY)

Contact No

Email

GP DETAILS

1. Within the last year, have you had any health problems that have affected or could affect your skin? 1. Within the last year, have you had any health problems that have affected or could affect your skin? Yes No

2. Are you prone to keloid scarring, blisters, or cold sores? 2. Are you prone to keloid scarring, blisters, or cold sores? yes No

3. List any medications, supplements, vitamins, diuretics, oral contraceptives, Isotretinoin, etc. that you take regularly.

4. Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments? 4. Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments? yes no

5. Do you have any allergies? 5. Do you have any allergies? yes no

8. List any allergies

6. What are your specific concerns/challenges with your skin?

7. What skin care products are you currently using? 7. What skin care products are you currently using? Soap cleanser toner spf moisturizer masque exfoliant eye products other

8. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 2 weeks? 8. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 2 weeks? yes no

9. Have you been waxed within the last 1-2 weeks? 9. Have you been waxed within the last 1-2 weeks? yes no

10. Are you currently using any products that contain the following ingredients? 10. Are you currently using any products that contain the following ingredients? glycolic acid lactic acid any exfoliating scrubs Other Hydroxy Acids Vitamin A derivatives (i.e., Retinol) none of these above

11. Please specify if any of the following apply to you: 11. Please specify if any of the following apply to you: Pregnant trying to become pregnant lactating menstruating pre-menstrual none of these above

12. Have you used retinol, tretinoin or any other prescription skin products within the last three months? 12. Have you used retinol, tretinoin or any other prescription skin products within the last three months? yes no

13. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? 13. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? yes no

14. Do you have active cold sores? 14. Do you have active cold sores? yes no

15. Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks? 15. Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks? yes no

16. Do you sunbathe or use tanning beds? 16. Do you sunbathe or use tanning beds? yes no

17. Do you experience redness, itching, or stinging on your skin? 17. Do you experience redness, itching, or stinging on your skin? yes no

precautions & warnings precautions & warnings

1. Skin may appear flushed following the treatment. 1. Skin may appear flushed following the treatment.

2. Peeling may begin within 2-3 days. DO NOT pick at loose skin, as this may cause discoloration. 2. Peeling may begin within 2-3 days. DO NOT pick at loose skin, as this may cause discoloration.

3. Avoid direct sun exposure for 2-3 weeks to prevent hyperpigmentation. 3. Avoid direct sun exposure for 2-3 weeks to prevent hyperpigmentation.

4. Avoid sweaty exercise on the day of treatment, along with steam rooms. 4. Avoid sweaty exercise on the day of treatment, along with steam rooms.

5. Avoid any type of exfoliating product until directed otherwise by Professional Skin Therapist. 5. Avoid any type of exfoliating product until directed otherwise by Professional Skin Therapist.

Contradictions Contradictions

1. pregnant or nursing women 1. pregnant or nursing women

2. open skin lesions or active cold sores 2. open skin lesions or active cold sores

3. recent resurfacing such as laser, microdermabrasion or chemical peel within 2 weeks 3. recent resurfacing such as laser, microdermabrasion or chemical peel within 2 weeks

4. use of isotretinoin currently or in the past six months 4. use of isotretinoin currently or in the past six months

5. severe rosacea or acne 5. severe rosacea or acne

6. prone to post-inflammatory hyperpigmentation or keloid scars 6. prone to post-inflammatory hyperpigmentation or keloid scars

7. recent sun exposure 7. recent sun exposure

8. history of diabetes 8. history of diabetes

9. received cosmetic injectables within 14 days 9. received cosmetic injectables within 14 days

Declaration Declaration I understand that failure to disclose information requested above may result in adverse side effects from treatment(s) received. Therefore I accept full liability/responsibility having read the Precautions & Warnings, and Contradictions of the treatment.

Technicians name

DD/MM/YYYY