Skincare Consultation

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Your Full Name

Contact Number

Date of Birth

Skincare Consultation: Please advise if any of these apply to you

Do you now or have you ever smoked? Do you have any known allergies? Are you pregnant or planning a pregnancy? Do you have metal implants or body piercings or a pacemaker Are you under a Doctor's care for any reason? Are you currently taking any prescription medication? Do you experience claustrophobia?

What is your specific concern about your skin?

Which brand/s of skincare are you using on your face? Cleanser, Serum, SPF, Exfoliant, Toner, Make-Up, Masques, Moisturisers

Please provide details and note dates for the above

Other information you feel may be relevant

Disclaimer: I will keep my therapist informed of any changes regarding my health. I have read and understand the Cancellation Policy. I recognise that my participation is voluntary and I’m happy to proceed.