Where * denotes a required field.
Full Name *
Email Address *
Phone Number *
Your GP's Name: *
Your GP's Address *
How did you hear about us?---Word of MouthSearch EngineNewspaperRadioTVFlyerOther
How did you hear about us?
Age Group: *Under 2020 – 3030 – 4040 – 5050 – 6060+
Details of activity:
Contra-indications that prevent treatment – (Select if/where appropriate): Active acneBlood borne diseasesHaemophiliaOpen wound(s)RosaceaImmunosuppressive therapy (MS,Lupus, RA)Allergy to surgical grade stainless steelContagious skin diseasesInflammation/swellingPhotosensitising medicationSkin CancerCardiac abnormalitiesAnticoagulant/steroid medicationHypersensitive skinIsotretinoin use in the last 6 monthsRecent scar tissueUndiagnosed lumpsCollagen vascular diseases/scleroderma
Contra-indications that restrict treatment – (Select if/where appropriate): AbrasionsBotox/dermal fillersCutsEpilation treatmentHerbal remediesHypersensitive skinLarge molesPoor mental/emotional stateRecent chemical peelVaricose veinsActive inflammatory dermatosesBruises/raised molesDirect sun exposure (past 24 hrs)EpilepsyHerpes SimplexIPL treatmentLong-term anti-inflammatory usePrior to cosmetic surgeryReactive skin typesEczema/Psoriasis/DermatitisAnxietyCurrent medicationsDiabetesFeverHistory of hypertrophic/keloid scarringLaser treatmentPiercingsRecent microdermabrasion treatmentSupplementsOther
Have you had any health problems in the past or present? *YesNo
Please provide further information:
Have you been under the care of a medical practitioner or other healthcare specialist in the last year? *YesNo
Are you currently using any prescription medications (oral or topical)? *YesNo
Are you currently using any supplements or herbal remedies (oral or topical)? *YesNo
Do you suffer from anxiety, stress, depression and/or are clinically diagnosed? *YesNo
What are your stress levels at home? (0 - 10 where 10 is highest) *
What are your stress levels at work? (0 - 10 where 10 is highest) *
Do you smoke? Have you smoked in the past/present? *YesNo
How many? *
Do you drink alcohol? *YesNo
How much? *
Are you trying to conceive, pregnant or lactating? *YesNo
Are you? Due or having your menstrual periodPeri-menopausalMenopausal
Do you have any allergies? *YesNo
What is your level of sun exposure? *
Are you currently sun/wind burnt? *YesNo
Do you wear a sun protectant? *YesNo
Do you suffer from Herpes simplex? (if yes take HS medication 5 days pre/post treatment) *YesNo
Have you had any of the following within the last 1-4 weeks? Botox/injectable dermal fillersDepilatory treatmentsElectrolysisFacial surgeryIPLRetin ALight based therapyLaserMicrodermabrasionSkin needlingSkin peelingPrescription skincare products
If yes, please specify treatment details (to include treatment dates, frequency, results and client satisfaction with outcome):
Have you used any home care products containing any of the following in the last 3 days? Exfoliating granulesOther Alpha Hydroxy AcidsGlycolic AcidVitamin A derivatives (Retinol)Lactic Acid
If yes, please specify skin reaction after use:
What is your current daily skincare regime A.M and P.M? Please list any and all products you use
What specific skin concerns do you have?
What are your expectations of this treatment?
I hereby declare that the information provided is true and correct to the best of my knowledge.