Client Consultation FormWhere you can, please answer to the best of your ability as this will be the best indication of what can be prescribed to you. Name * First Name Last Name Date of birth * MM DD YYYY Address Phone number * Email * Preferred method of contact Phone Email LET'S TALK ABOUT YOUR SKIN If there was one thing you could change about your skin, what would it be? * What are your current concerns about your skin? * One or more can be ticked Acne Blackheads Broken capillaries Congestion Dullness Dry/Dehydrated skin Enlarged pores Fine lines/wrinkles Impaired barrier Not plump/loss of firmness Oily skin Pigmentation or blemishes Redness Scarring Sensitivity Uneven skin tone NONE OF THE ABOVE Please specify if not listed above On a scale of 1 - 10, how do you feel about your skin overall? * (1 being the lowest, 10 being the highest) Have you previously had any skin treatments? And/Or Injectables? * Yes No If so, please list when and what treatment MEDICAL HISTORY Are you currently taking any medications including topical creams? Are you allergic to anything? (Medications, food/drinks, materials)? Are you currently pregnant, breastfeeding or trying to conceive? Are you currently under a physician's care for anything skin related? * Yes No If so, please specify: Have you previously or are you currently diagnosed with any of the following? * If you tick any, treatment MAY or MAY NOT be performed Blood Clotting Cancer Claustrophobia Cold Sores Diabetes Epilepsy High/Low Blood Pressure HIV/AIDS Pacemarker PCOS (Polycystic Ovary Syndrome) Psoriasis Thyroid NONE OF THE ABOVE Please specify if you have ticked any of the above Have you had any recent surgery or admission to the hospital in the past 12 months? * Yes No If so, please specify: LIFESTYLE What is your nationality/background? * Besides medication, do you take supplements or vitamins? Yes No If so, please specify: What is your occupation? Do you...? Drink Smoke Recreational drugs Do you exercise? If so, what type? Do you stress? If so, on a scale of 1 - 10 (1 being the lowest, 10 being highest) COVID RELATED Q'S Have you experienced any cold or flu like symptoms in the last 2 weeks (14 days) including cough, runny nose, fever, sore throat, fatigue? * Yes No Have you just returned from overseas in the last 2 weeks (14 days) and/or been a close contact with someone who has COVID? * Yes No Consent for photography * I consent to have photos/videos taken of my skin and/or face I consent to have photos/videos taken of me, AS LONG AS MY IDENTITY IS HIDDEN I don't consent Emergency contact details * First Name Last Name Emergency contact phone number * Consent for treatment * I hereby authorise for the trained clinician at Dermal Edit (ABN: 46866701107) to perform the skin treatments on me. I am over 18 and have given the correct details and history information about me and I accept full responsibility. I have read, understood and will follow all the aftercare information given to me, and I am responsible for all general care of my skin. (Full name below) Today's date MM DD YYYY Thank you for your submission! Let’s review it together :)
