___ NO. ___ I am trying to quit. 6. Do you currently have or/ are you prone to SKIN SENSITIVITIES? ___ Skin rash. ___ Sunburn. ____ Eczema. ___ Skin Graze.
74KB Sizes 3 Downloads 121 Views


CONSULTATION FORM Welcome to SABR MEDI SPA. So we can prepare for your treatment today, please complete this form and return it to reception prior to your appointment.

CLIENT INFORMATION FIRST NAME _______________________________________

GENDER _________ FEMALE _________ MALE

SURNAME ______________________________

DATE OF BIRTH _____/______/_____

ADDRESS ________________________________SUBURB _______________PCODE_________ STATE _____

TELEPHONE ________________________ MOBILE ___________________ EMAIL ________________________

MEDICAL CARE QUESTIONAIIRE (Please Tick) 1. Are you currently taking any MEDICATION? __ Hormones

__ Antibiotics

__ High/Low Blood Pressure

__ Steroids

__ Roaccutane

__ Birth Control

__Anti-Depressants (Inc. St John’s Wart or natural remedies)

__ Other photosensitive medication

If yes, please provide name and Dosage __________________________________________________________

2. Do you have any current MEDICAL CONDITIONS? __ Hemophiliac

__ Polycystic Ovaries

__ Hormonal Imbalances

__ Thyroid

__ Hirsutism

__ Digestive

__ Cancer

__ Diabetes

__ Hepatitis

__ Nervous System

__ Circulatory

__ Gynecological

__ Respiratory

__ Panic / Nervous disorder

__ Asthma

__ Closterphobia

__ Difficulty Breathing

__ Nausea

__ OTHER (Please explain) ___________________________________________________________________

3. Have you had SURGERY in the past two years? __ YES

__ NO

If yes please explain & provide date ___/____/_______________________________________________________

4. Are you currently PREGNANT? __ YES

__ NO

__ I am trying to conceive

5. Do you currently SMOKE? ___ YES

___ NO

___ I am trying to quit

6. Do you currently have or/ are you prone to SKIN SENSITIVITIES? ___ Skin rash

___ Sunburn

____ Eczema

___ Skin Graze

___Open wound / cuts

____ Bruising

___ Skin Irritation

___ Psorasis

____ General soreness

If yes, please explain where on your body, is the affected area:

7. Has your skin been EXPOSED TO SUNLIGHT over the past 2 weeks? _____________________________________________________________________________________________

8. How many glasses of WATER do you consume daily? ___1-2




9. Do you currently have any of these on or inside your body? __ Tattoos

__ Body Piercing

__ Metal Pins

__ Metal Plates

__ Metal Fillings

__ Other Metal Internally

__ A Pacemaker

10. For LASER LIPO we require you to remove all jewelry including piercings. Do you have any allergies? If yes, please list: ___________________________________________________________________________________________

11. Do you have any OTHER MEDICAL conditions or health concerns, we need to be aware of? If yes, please explain:

At SABR MEDI SPA, your safety is just as important to us, as your beauty. Prior to booking your first IPL, Laser or microdermabrasion treatment, SABR MEDI SPA will require a skin patch test be completed to the affecting area. Your beautician will apply this for you. Should you show signs of any skin allergies or health reactions within 48 hours of receiving your patch test, due to high risk factors, you will not be able to commence your treatment. In, this instance, your beautician will provide you with other treatment opt