Consult

Date*

Date

Name*

First NameLast Name

Date of birth*

Date

Phone Number

What are your skin care challenges?*

Please feel free to go into more detail about yur skin condition.

Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals. If you filled this in for a prior treatment and nothing has changed please leave BLANK

Cleanser / Face Wash

Face scrub / Exfoliants

Toner

Serums

Moisturisers

Sunscreen

Other

Do you/have you used AHAs / BHAs/Benzoyl Peroxide, Hydroquinone, Adapalene, Retinol, or other Vitamin A derivatives?*

Please specify which product or type, if you answered 'Yes, currently using, or Not sure. Also please specify when you last used this product.

Have you had any of the following within the last 6 weeks*

If checked, please specify treatment details (to include treatment dates)

Have you received any Botox, Juvederm, or other dermal fillers in the last 4 weeks?*

YesNo

If yes, please specify when

Have you experienced any of these health conditions in the past or present?*

If you checked yes to any of these or other, please provide further information.

Have you had recent surgery within the last 6 months?**

YesNo

If you checked yes, please provide further information.

Are you taking any medication or supplements (Including Antibiotics)**

YesNo

If yes, please list

Are you currently taking (or have taken in the last 6 months) any of the following medications - Isotretinoin/ Roaccutane/ Accutane/Isotane*

YesNo

If yes, please specify when

Have you used or been prescribed any other medications (topical or oral) for acne / acne control?*

YesNo

If yes, please specify what and date last used

Do you suffer from any allergies to foods, medicines, insect bites or any other reactions?*

YesNo

If yes, please give details

Are you a smoker?*

YesNoSocial

Have you ever experienced claustrophobia?*

YesNo

Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and breastfeedingN/A

Do you consent to pictures/videos being taken? This will be posted on the Skin Specialist instagram page / story ONLY*

YesNo

Have you experienced any of the following symptoms in the last 14 days?*

Have you recently travelled internationally in the last 15 days?*

YesNo

If yes, where and when?

Possible side effects - Contact dermatitis (rash)/ itch /Bruising/ Infection if the area is not kept clean/pigmentation (although rare, this can happen in darker skin) / hypopigmentation/ purging/ redness*

I have read the possible side effects

I understand success varies from person to person and depends on the severity of the skin issue as to how many treatments may be required.

Yes

I understand that the practice of skin treatments is not an exact science and therefore that no guarantee can be given as to the results of the treatment. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.*

Yes

Post Facial Care: Aerobic exercise and/or vigorous physical activity should be avoided for 5 days. No make-up for 6 days if having a Green peel treatment/Advanced Cosmetic Blemish Removal. Direct sunlight exposure is to be avoided immediately following any treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 50. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitive to the sun as a result of this treatment. Green peel - Your skin will peel between day 2-5, you must not wet your face for 5 days but a homecare kit is given. You can possibly develop contact dermatitis (an itchy rash) this is usually caused by sensitive skin not an allergic reaction, this will pass, but I must be informed so it can be controlled. Itchy skin is normal with the green peel. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them. (Post care instructions will be provided after treatment with The Skin Specialist)

I understand and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.*

Yes

Do you want a silent appointment with little conversation? Some days we don’t feel like talking much and that is ok!*

YesNo

Are you signing on behalf of someone else? (under 18)*

YesNo

If yes, please add your full name in the box as well as signing

Signature*

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Green Peel/Advanced Cosmetic Blemish Removal - Confidential Medical Consent Form

About Your Skin

Your Health