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Facial & Skincare
Consultation Form

Do you have any pre existing medical conditions or chronic illnesses? Please describe if yes.
Are you currently taking any medications or supplements?
Have you had any recent surgeries or medical procedures?
Have you had any allergic reactions to medication sor substances in the past? Please describe.
Do you have any known skin allergies or sensitivies?

Facial & Skincare History

Have you had any previous treatments or procedures for our face or skin? If yes, please describe.
Do you have any history of skin conditions, such as acne, rosacea, or eczema? If yes, please describe.

Treatment Considerations

Are you a smoker or regularly exposed to secondhand smoke?
Do you frequently expose your face to the sun? Do you use sunscreen on your face?
Do you engage in activities that might stress or damage your skin, such as intense physical activity or outdoor work?
Are you following any specific dietary restrictions or diets that could impact your skin health?
Are you aware of the post-treatment care needed to maintain optimal results?
Do you have any upcoming events or occasions that could affect your availability for treatment or recovery?
Are you willing to follow post-treatment care instructions, including using specific products or avoiding certain activities?
Are you pregnant or breastfeeding?
Have you recently undergone exfoliating or peeling treatments on your face?

If having microneedling

I understand the expected downtime (48 hour aftercare) associated with microneedling treatment and confirm that I have no known allergies to nickel.
I am aware that I should avoid active ingredients (retinoids/vit c) ideally 48 hours pre & post procedure.
I can confirm that I have NOT been on / prescribed Roaccutane in the past 6 months

Thanks for submitting!

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