Skin Consultation FormPlease complete this form prior to your appointment. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth MM DD YYYY Gender Female Male Other I don't want to share Address Address 1 Address 2 City State/Province Zip/Postal Code Country DESCRIBE YOUR SKIN What special areas of concern do you have? * Acne scarring Fine lines & Wrinkles Hair Removal Pigmentation Sun Damage Stretch marks Age spots Scars Acne Rosacea/ eczema/ dermatitis Moles Warts Birthmarks My skin feels * Comfortable & balances Sensitive & irritated Dry & tight Flaky & rough Oily & bumpy Have you ever had Microdermabrasion Laser Hair Removal Restylane Botox Body treatments Cosmetic surgery Cosmetic fillers Collagen injections Chemical or Natural Peels Laser treatments LED Light Therapy Do you bruise easily? * Yes No Do you get cold sores/ blisters? * Yes No List the skincare products and brands you are currently using. * How would you rate your skin? select one. * Always burns, never tans Burns easily, tans slightly Burns moderately, tans gradually Seldom burns, always tans well Rarely burns, deep tan Never burns, deeply pigmented Do you use sunscreen/ SPF daily? * Yes No DESCRIBE YOUR HEALTH How would you describe your overall health? Excellent Good Fair Poor Do you currently have or have ever had any of the following Epilepsy or seizures Porphyria Lupus Erythematosus Photosensitive Eczema Albinism Skin cancer Eye disease Are you currently undergoing Cancer treatments? * Yes No I am, or there's a chance I could be pregnant * Yes No Do you have any other medical conditions including allergies? If YES please specify * Are you taking or applying topically any prescription medications? Certain medications can induce photosensitivity and may be contra-indicated for the Dermalux treatment. If YES please specify * Are you currently taking St John’s Wort or other herbal remedies? * Yes No Have you ever had a reaction to Metals Medication Food Fragrance Airborne Particles Cosmetics Other Allergies (Milk, Apples, Citrus, Grapes, Aloe Vera, Aspirin) LIFESTYLE & DIET What is your occupation? Do you normally sleep well? Yes No Do you smoke? Yes No Do you have an outdoor lifestyle/activities? Yes No Do you use sunbeds? Yes No Do you have food intolerances? If YES, please specify * Do you follow any special diet? If YES, please specify * What is your stress level? * Low Medium High What is your daily water intake? * How many cups of caffeine-type beverages (coffee, tea, soft drinks) do you consume daily? None 1-3 cups 4 or more What do you consume on a daily basis? * Protein Complex carbohydrates Vegetables & Salad Fruit SOCIAL MEDIA Are you comfortable with us documenting your skin journey on our social media platforms? * Yes Yes, but please keep me anonymous No COMMITMENT How committed are you to achieving results? * Not sure Mildly committed Very committed Would you like to discuss package options with your Dermal Clinician to help treat your skin concerns? We always consider your budget and time when recommending a treatment plan and do not over exaggerate what your skin needs. Yes No I am making a booking because * I want to relax (minimal talking as possible during treatments) I want results I want information I have a gift voucher Don't really know Would you like relaxation music played during your treatment? Yes No Not sure We will discuss certain recommendations to assure the success in your treatment program such as daily water intake and/or home care regimen. During the course of your treatment, it may be necessary to recommend adjustments to your program. Would that be okay with you? * Yes No Do you agree to join our Mailing List and be first to find out on exclusive monthly promotions as well as new treatments. Please note we do not spam. Yes No Would you like to receive a personalised skincare routine based on your skin concerns emailed to you? Yes No Additional notes for the Dermal Clinician CLIENT CONSENT I confirm that I have answered all the questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effects. I will inform my therapist before every treatment if there has been any change to my circumstances or medication I may be taking. I understand that the Dermalux systems have not been tested on pregnant women and therefore the risk to the foetus or pregnant woman is unknown. I understand the benefits and likely clinical outcome of the skin treatments and that multiple treatments are necessary to achieve optimal results. I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made to me regarding the outcome of the procedure. I agree that I have read and understood all the information provided. My questions have been answered satisfactorily and I have made an informed decision to receive the skin treatments. * I agree to the statement above PRINT NAME First Name Last Name Date MM DD YYYY Thank you! We look forward to seeing you in your appointment :)
