___ NO. ___ I am trying to quit. 6. Do you currently have or/ are you prone to SKIN SENSITIVITIES? ___ Skin rash. ___ Su
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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
___3-5
___5-10
__10+
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 options.
DECLARATION
I ____________________________ have completed this SABR MEDI SPA consultation form to the best of my knowledge. I understand the risks involved and feel confident to proceed with my treatment, as scheduled today. I also understand, any personal information provided will remain confidential however at times, may be used for Internal skin analysis research & marketing to maintain the ultimate SABR MEDI SPA experience.
SIGNATURE __________________________________________________
DATE ________/_______/_______
PREFERRED BEAUTICIAN__________________________ REFERRED BY ______________________________
OFFICE USE SIGNED IN BY SABR BEAUTICIAN ________________________________
DATE ______/________/_______
ADDITIONAL COMMENTS
[email protected] 7/217 Cnr Wanneroo Rd & Morley Drive, Tuart Hill, WA 6060 +618 9440 0088
[email protected] 2/160 Pinjarra Road, Mandurah WA 6210 +618 95829788 Follow us on Fbk / Twt / Inst @sabrmedispa WA MEDI SPA CLINIC specialising in IPL Hair Reduction, Laser Lipo Body Sculpting, LED & microdermabrasion skin resurfacing facials. SABRMEDISPA.COM
