CONSULTATION FORM

Please fill out this Consultation Form prior to your appointment. This ensures my records are kept up to date, and you receive the very best care and treatment from me based on your personal circumstances.

Thank you.

Name

First Name

Last Name

Date of birth

YYYY

Address

Preferred Contact Number

Okay to leave messages?

YES

Please list any medication you take & please indicate what they are for:

Do you have any allergies?

Does your current skincare regime include retinol products?

YES

Have you had any recent surgeries or medical procedures?

Yes

If yes, please provide a little more information

If you have any medical issues I should be made aware of, please provide more information here

Please use the space below to cover anything of note that you think I may have missed.

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I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatment received.

I understand that by choosing YES below and submitting this form, it acts as my electronic signature.