Consultation Form - Louise Pynen Advanced Beauty and Aesthetics

Name *

First

Last

Date of birth (dd/mm/yyyy) *

Contact number *

Email *

Doctor's details *

I give consent for Louise Pynen Advanced Beauty & Aesthetics to contact me via the following: (select all that apply) *

Phone
Email

Do I have permission to show non-identifying photos for your records and social media purposes? *

Yes
No

Concerns (please tick all that apply) *

Other: please describe

How would you describe your skin? *

OILY
DRY
COMBINATION
SENSITIVE

How would you describe your stress levels? *

SLIGHT
MODERATE
HIGH

Are you currently under the care of a GP? *

Yes
No

Please provide more details

Medical History *

Please provide more details for any items you ticked

Are you taking or applying topically any prescription medications?

Yes
No

Please provide more details

How is your diet? *

POOR
MODERATE
ON THE RUN
BALANCED

Daily water intake (glasses) *

Daily alcohol intake (units) *

Daily caffeine intake (cups) *

How do you sleep? *

DEEPLY
LIGHTLY
DISTURBED

Have you ever had a reaction to a facial or body treatment before? *

Yes
No

Please provide more details

Please tick the skin care products you are using *

Other: please describe

Have you started using any new skin care products in the last month? *

Yes
No

Please provide more details

Are you currently taking St John’s Wort or other herbal remedies? *

Yes
No

Please provide more details

Do you smoke? *

Yes
No

Do you have an outdoor lifestyle/activities? *

Yes
No

Please provide more detail to explain your outdoor lifestyle including details of the activities

Have you undergone any cosmetic/aesthetic procedures in the last 7 days? *

Yes
No

Please provide more details

General Disclaimer

• I understand multiple treatments may be necessary to achieve optimal results
• I understand that is no guarantee of permanent results and maintenance treatments may be required
• I understand that there be side effects or bruising, reddening, swelling and rarely mild burning or blistering.
• I understand the Dermaplaning treatment involves the use of a sterile surgical blade to remove dead skin cells and vellus hair. As with the use of any sharp instrument there is a risk nicks or cuts while every precaution is taken, I understand the risk

Dermalux Flex MD Disclaimer

• I confirm that I have answered all the questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effects.
• I will inform my practitioner before every treatment if there has been any change to my circumstances or medication I may be taking.
• I understand that the Dermalux systems have not been tested on pregnant women and therefore the risk to the foetus or pregnant woman is unknown.
• I understand the benefits and likely clinical outcome of the Dermalux treatment and that multiple treatments are necessary to achieve optimal results.
• I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made to me regarding the outcome of the procedure.
• I agree that I have read and understood all the information provided. My questions have been answered satisfactorily and I have made an informed decision to receive the Dermalux treatment.

Today's date

Signature *

Dermaquest, Dermaplaning, Microneedling, Dermalux Flex MD and Platelet Rich Plasma (PRP) Consultation form.

General Disclaimer

Dermalux Flex MD Disclaimer