Consultation – Carley Harrison

SKIN CONSULTATION FORM

Name

First

Last

Address

Town

County

Postcode

Date of Birth

Telephone

Email

Tick if you are prone to any of the following

If Yes please indicate where on the body and for how long.

Tick if you are, or have, any of the following conditions

If you ticked any of the above please tell us more here.

Tick if you have been treated with any of the following

If you ticked any of the above please tell us more here

Are you having or have you had any of the following

CST (Immediately after treatment) IPL (Immediately after treatment)

Laser Treatments (Wait 2 weeks) Microdermabrasion (Immediately after treatment) Electrolysis (Wait 2-3 days)

Facial Waxing

Botox (Wait 2 weeks)

Fillers (Consult Practitioner)

Other skincare treatments

If you answered yes to any of the above tell us more.

Do you have any known allergies

Yes

No

Tell us more about your allergies

Sonophoresis Caution - Please Tick if you have either

Hearing Implants

Tinitus

Supplements

Please tell me which vitamins and supplements you take and any that you take for your skin.

Skincare regime

Please describe which skincare products you use.

Make Up

Please describe which make up products you use.

Describe your environment (Tick all that apply)

What kind of sun exposure do you get?

On average how many hours of sleep do you get each night

Your Diet

Tell me about your diet, include details of the foods you eat, your sugar intake, your alcohol intake and if you are a smoker.

Main Concerns

What are your main concerns regarding your skin

Your Goals

What are your main skincare goals

Signature

Clear