CLIENT CONSULTATION FORM Name: ______ Date: Address:___

Electrolysis. YES / NO. Roaccutane therapy YES / NO. Laser Treatment. YES / No. Intense Pulsed Light YES / No. Photo Rejuvenation YES / NO. If Yes when?
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CLIENT CONSULTATION FORM Name:_______________________________________________ ______

Date:_________________________

Address:___________________________________________________

Date Of Birth:__________________

Suburb:____________________________________________________

Post Code:_____________________

Telephone Work:________________________________________ Home:___________________________________ Mobile:_______________________________________ Email:___________________________________ How did you hear about us?_________________________________________________________________________ MEDICAL BACKGROUND Are you currently under Doctor’s care?

YES / NO

If yes for what? Please List any prescription or non prescription medication you are taking including anything topical or herbal ___________________________________________________________________________________________ _________________________________________________________________________________________________ Have you had surgery in the last 6 months

YES / NO

If yes please explain:________________________________________________________________________________ Are you pregnant or trying to conceive?

YES / NO

Have you got any allergies or sensitivities?

YES / NO

If yes, please explain:________________________________________________________________________________ Have you ever had any of the following treatments? Chemical Peels

YES / NO

Skin resurfacing

YES / NO

Electrolysis

YES / NO

Roaccutane therapy

YES / NO

Laser Treatment

YES / No

Intense Pulsed Light

YES / No

Photo Rejuvenation

YES / NO

If Yes when?_______________________________________________________________________________________ Have you ever experienced any of the following ? Skin Cancer Cold Sores

YES / NO YES / NO

Photosensitivity Haemophiliac

YES / NO YES / NO

Cancer Epilepsy

Keloid

YES / NO

Diabetes

YES / NO

Removal of skin Lesions YES / NO

Any skin pigment changes

YES / NO YES / NO

YES / NO

If yes, please explain and include dates:_________________________________________________________________ Note: Any changes to medical history or medications must be notified. Technician Initial:____________________________

Client Signature:______________________________________