Skin Profiling AnalysisRecommendation SheetNameTherapistDatePrimary Skin TypePrimary RangePrimary Aromatic SerumAdditional advice about your skinAdditional recommendationsTonerCleanserMasqueExfoliantEye treatmentSerum / Target treatmentProtect & PrimeMoisturiserQuestion to ask every visitAre you currently taking prescription medication or under a doctors care?I can confirm to the best of my knowledge that the answers I have given and are correct and that i have not withheld any information that may be relevant to my treatment. I have read the privacy notice regarding health information and consent to my health information being processed for the purposes of determining the safety of treatments. In addition to the health information provided, further information may be required for certain procedures.Client SignatureStart signing your signature hereYour browser does not support e-Signature field.DateTreatment received / products usedTherapistClient date of birthTelephoneAddress or emailClient nameChosen method of contactClient SignatureStart signing your signature hereYour browser does not support e-Signature field.I acknowledge that on occasion it may be required that I am contacted regarding my appointments, I have read the privacy agreement and give my consent for this.Health historyPlease list any medication you are currently takingPlease list any surgeries you have hadDo you have any known allergiesPlease list any serious illness you have experiencedAre you pregnant or planning a pregnancyDo you now or have ever smoked?Do you have metal implants, body piercing or pacemaker?Are you pregnant or planning a pregnancyAre you in a doctors care for any reason?Do you experience claustrophobia?Nutrition and lifestyleWhat percentage of your average daily diet is processed food?What percentage of your average daily diet is fresh food?How many of the following drinks do you consume on a daily basis?TeaWaterFizzy drinksCoffeeAlcohol/Wine/BeerHow often do you exercise?What is your favourite past time?What is your current occupation?On a scale of 1-10 how would you measure your current stress level?Would you say your sleep patterns areAdequateNot enoughPlentyHow much UV exposure do you have now and in the past?Your skinDo you ever experienceFlakinessTightnessRednessBreakoutsOily shineIs this ongoing or a temporary condition?What is your specific concern with you skin?What specific improvements do you wish to see?Have you ever received a salon/spa treatment before?What were the results?Skincare productsWhich brand of skin care are you using of the following on your face?CleanserExfoliantMasqueSerumTonerMoisturiserSPFMake-upOtherWhich brand of skin care are you using of the following on your body?CleanserExfoliantSPFHair removalMoisturiserOtherPrevious invasive treatmentsHave you ever had any of the following month treatments, if so please mark the latest treatment date?Dermal fillersBotoxIPL / LaserChemical peelMicro-dermabrasionFacial waxingPractitioner SignatureStart signing your signature hereYour browser does not support e-Signature field.Practitioner NameI accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.Your browser does not support e-Signature field.Submit results
