Our Online Skin Consultation is €40, redeemable against products within 7 days of your consultation. Please fill in the below form and we will be in touch.
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
HAVE YOU EVER BEEN TREATED FOR CANCER? IF YES, WHEN AND WHAT TYPES OF THERAPIES WERE USED? YesNo
DO YOU WEAR CONTACT LENSES? YesNo
DO YOU HAVE ANY ALLERGIES? YesNo
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*
