Facial consultation

Please answer these questions to allow us to perform a fully professional treatment.

Your first name *

Reference (from your booking confirmation) *

Have you experienced any cold or flu-like symptoms in the last 10 days (including fever, cough, sore throat, respiratory illness, difficulty breathing)? *

• Yes
• No

If yes, please give details

Please tell us about any health conditions or allergies you have or if you are pregnant

Name of an emergency contact

Emergency contact number

Have you used aesthetic medicine treatments using Botox? *

• Yes
• No

If yes, please give details below

Have you used aesthetic medicine treatments using hyaluronic acid? *

• Yes
• No

If yes, please give details below

Have you used permanent make-up? *

• Yes
• No

If yes, please give details below

Have you used aesthetic medicine treatments of needle/microneedle mesotherapy? *

• Yes
• No

If yes, please give details below

Have you had face lift surgery? *

• Yes
• No

If yes, please give details below

Have you had microdermabrasion in the last week? *

• Yes
• No

If yes, please give details below

Have you used a lifting thread treatment? *

• Yes
• No

If yes, please give details below

If you have answered 'Yes' to any of these questions, please give details including dates.

Do have any of these contraindications? – Acute inflammation of the body (fever) *

• Yes
• No

– Inflammation of the skin (allergic and infectious) breaking the continuity of the epidermis *

• Yes
• No

– Hypertension (high blood pressure) *

• Yes
• No

– Recent tooth extraction, pus around the tooth *

• Yes
• No

– Rosacea in the exacerbation phase *

• Yes
• No

The effects of treatment depend on age, health and lifestyle and are not identical for each client. I declare that I have read the above, and have not concealed any information. I consent to receiving facial treatment. *

• Yes
• No

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