GDPR & Medical / Aesthetics Consultation Form

Please state if you have / had any of the following
I have had surgery within the last 6 monthsI have had lymph nodes removed or radiatedI have a pacemaker or a heart or circulatory disorderI have had deep vein thrombosisI am currently breast feeding/pregnantI have allergiesI have an infectious diseaseI have a skin condition/open sore/woundI have a chest or breathing disorderI suffer from lymphedema, neuropathy or vascular disordersI suffer from epilepsyI often feel faint/dizzyI have suffered a recent fracture/muscular injury/metal pins or platesI suffer from backbone, or other muscle and/or joint disordersI am claustrophobicI am currently receiving medical treatment which I feel may affect my suitability for treatment

Do you have any of the following skin conditions?
AcneLarge PoresAcne ScarringDehydrated SkinCysts / NodulesAge SpotsOily SkinMelasmaRednessDull ComplexionBlackheadsExcessive Facial HairRosaceaBody AcneRough / Uneven Skin TextureMiliaSun DamageFrequent BreakoutsAllergy to Latex

Are you currently under the care of a GP for a skin issue?
YesNo

Do you smoke?
YesNo

Are you prone to cold sores?
YesNo

Do you tan regularly (in the sun or tanning beds)?
YesNo

Have you had a reaction to a facial or body treatment/product before?
YesNo

Have you received a face peel in the last 14 days?
YesNo

Have you received any laser treatments in the last 4 weeks?
YesNo

How would you describe your skin type?
OilyDryCombination

How would you describe your current stress level?
LowModerateHighSevere

Please select which skin care products you are currently using:
CleanserTonerMoisturiserFacial OilSerumSPFEyecreamExfoliating ScrubSelf TannerEnzymesMake up

I understand that certain medications eg Aspirin, Accutane may preclude dermaplane treatment due to the possibility of nicks and cuts.
YesNo

I understand that Dermaplaning involves the use of a sterile, surgical blade to remove dead skin cells and vellous hair. I understand that there is a risk of nicks and cuts.
YesNo

Are you happy to receive limited marketing communications from us?
I consent to marketing by postI consent to marketing by emailI consent to marketing by phoneI consent to marketing by SMS

Please add notes here that you would like your therapist to be made aware of: