Online Skin Consultation

Contact Details

Name

Email

Phone Number

Date of Birth

Address

Doctor's Name & Contact

CONSULTATION:

HAVE YOU USED ANY ALPHA HYDROXY ACID (AHA) OR GLYCOLIC PRODUCTS IN THE PAST 48-72 HOURS?YesNo

ARE YOU USING RETIN-A, RENOVA OR ACCUTANE (AN ORAL FORM OF RETIN-A)? YesNo

ARE YOU USING ANY SKIN THINNING PRODUCTS OR DRUGS? YesNo

ARE YOU PREGNANT OR NURSING? YesNo

ARE YOU EXPOSED TO THE SUN OR SUNBED? YesNo

DO YOU SUFFER FROM EPILEPSY OR DIABETES? YesNo

ARE YOU CURRENTLY TAKING ANY MEDICATIONS? YesNo

If Yes, please share:

ARE THERE OTHER MEDICAL CONDITIONS OR ISSUES THAT YOUR THERAPIST SHOULD BE AWARE OF? YesNo

If Yes, please share:

HAVE YOU EVER BEEN TREATED FOR CANCER? IF YES, WHEN AND WHAT TYPES OF THERAPIES WERE USED? YesNo

If Yes, please share:

DO YOU WEAR CONTACT LENSES? YesNo

DO YOU HAVE ANY ALLERGIES? YesNo

If Yes, please share:

DO YOU HAVE ANY SKIN CONDITIONS SUCH AS PSORIASIS? YesNo

DO YOU HAVE ANY RECENT SCARS (UNDER 6 MONTHS OLD) OR SUFFER FROM KELOID SCARRING? YesNo

SKIN CONCERNS:

WHAT IS YOUR MAIN CONCERN WITH YOUR SKIN?

WHAT WOULD YOU LIKE TO ACHIEVE?

DO YOU EXERCISE AND HOW OFTEN?

HOW MUCH SLEEP DO YOU GET PER NIGHT?

HAVE YOU EVER HAD CHEMICAL PEELS, LASER OR MICRODERMABRASION? YesNo

WHAT SKIN CARE PRODUCTS ARE YOU CURRENTLY USING? (LIST BRAND WHERE KNOWN)

WHAT AREAS OF CONCERN DO YOU HAVE REGARDING YOUR SKIN: (PLEASE CHECK ANY THAT APPLY AND EXPLAIN) BREAKOUTS/ACNEBLACKHEADS/WHITEHEADSEXCESSIVE OIL/SHINEROSACEABROKEN CAPILLARIESREDNESS/RUDDINESSDEHYDRATEDSUN SPOTUNEVEN SKIN TONESUN DAMAGEWRINKLES/FINE LINESDULL/DRY SKINFLAKY SKIN

Please elaborate:

HOW MUCH WATER DO YOU DRINK A DAY?

DO YOU HAVE A HEALTHY DIET?

DO YOU CONSUME A LOT OF SUGAR?

ARE YOU TAKING THE CONTRACEPTIVE PILL?

DO YOU SMOKE OR DRINK?

CONSENT:

I HAVE BEEN ADVISED THE SERVICE(S) PROVIDED TO ME BY THIS SALON COULD HAVE UNFAVOURABLE RESULTS INCLUDING, BUT NOT LIMITED TO: ALLERGIC REACTION, IRRITATION, BURNING, REDNESS, SORENESS, ETC.

I AM AWARE THAT CERTAIN MEDICATIONS AND OVER THE COUNTER PRODUCTS CAN SIGNIFICANTLY INCREASE THE RISK OF INJURY WHEN COMBINED WITH SERVICES. I UNDERSTAND THAT SERONA BEAUTY AND LASER CLINIC DOES NO RECOMMEND SERVICES FOR CUSTOMERS USING RETIN-A, ACUTANE AND PRODUCTS CONTACTING ALPHA HYDROXYL, OR ANY OTHER SKIN THINNING TREATMENTS.

I HEREBY CONFIRM THAT I AM NOT USING ANY MEDICATIONS THAT MAY CAUSE OR CONTRIBUTE TO SUCH INJURY/REACTION, AND I WILL ADVISE MY THERAPIST SHOULD I USE ANY SUCH MEDICATIONS IN THE FUTURE.

I UNDERSTAND THERE ARE OFTEN RISKS ASSOCIATED WITH SERVICES, AND I AGREE THAT AS A CONDITION OF PROVIDING THESE SERVICES ON AN ON GOING BASIS, I WILL NOT HOLD SERONA BEAUTY AND LASER CLINIC AND THERAPIST LIABLE.

Your Personal Information

Except for where you have separately granted Serona Skin & Laser Clinic permission to store and process your before and after photographs and face scan data, Serona Skin & Laser Clinic itself does not store or process your other personal and medical data as captured in this form - please liaise with the salon directly to understand its arrangements for data security and compliance with data legislation.

TO THE BEST OF MY KNOWLEDGE THE MEDICAL INFORMATION I HAVE SUPPLIED IN THIS FORM IS RELEVANT AND FACTUALLY CORRECT. BY CHECKING THIS BOX I ACCEPT THIS AS A DIGITAL SIGNATUREI agree*