SKIN CARE & LASER ASSESSMENT FORM

1. How did you hear about our Aesthetic Department?

Clinic Website

Google Search

SMS

Existing Clinic Patient;

Referred by:

2. What is your major skin concern?

3. Does your job require that you work outdoor?

Yes

4. What would you like to achieve from your treatment today?

5. Have you ever had any of the following treatments?

Facial Treatments

Chemical Peels

Microdermabrasion

Mesotherapy

Laser Treatment

Laser Hair Removal

VelaShape

Other Treatments:

If yes, when:

- Do you use Retin-A based Medicarions (Roaccutane) or Retinol creams?

Yes

- Do you use any Antibiotic or Photosensitive pills?

Yes

If yes, please describe:

- Do you have any special skin problems or concerns related to your face or body?

Yes

Specify:

- Do you have any allergy?

Yes

No Specify:

- Do you have Epilepsy?

Yes

- Do you have any metal implants?

Yes

- Did you have any surgery in the last 6 months?

Yes

if YES, When?

Acknowledgment:

I understand, 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 any irritation to the skin from the treatments received. The treatments I receive here are voluntary, and I release this institution and/or skin care & laser professional from liability and assume full responsibility thereof.