Facials consultation card

First name

Last name

Phone

SMS subscribe

Multi-line address

Country/Region

Address

City

Zip / Postal code

Pleases leave instructions for parking. FREE immediate parking is required

Short answer

Birthday

Month

Day

Year

Heart condition

Yes

if Yes, elaborate more

High or low blood pressure

Yes

if Yes, elaborate more

Diabetes

Yes

if Yes, elaborate more

Cancer

Yes

if Yes, elaborate more

Have you ever used Acne medications?

Yes

if Yes, elaborate more

Have you ever had chemical peels, laser or microdermabrasion?

Yes

if Yes, elaborate more

Loss of skin sensation

Yes

if yes, elaborate more

Pregnancy

Yes

if Yes, elaborate more

Epilepsy

Yes

if Yes, elaborate more

Do you use Retin-A, Retinova, AHA or Retinol products?

Yes

if Yes, elaborate more

Recent scars or surgeries under 6 months

Yes

if Yes, elaborate more

Skin disorders

Yes

if Yes, elaborate more

Medications

Yes

if Yes, elaborate more

During chemotherapy or radiotherapy?

Yes

if Yes, elaborate more

What skin brands and routine you follow

What areas of concern do you have regarding your skin?

Breakouts/Acne

Blackheads/Whiteheads

Excessive Oil/ Shine

Alergies

Yes

if Yes, elaborate more

Please upload Doctors notes, if you got medical condition or need adaptation to your treatment or upload proof for parking

Upload your file

Choose a file or drag and drop one here.

I agree with terms and conditions and information given is true

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

I agree to inform immediately, if my body temperature is getting higher than 37 °C, develop cough or loose my sense of teste and smell in the last 24 hrs prior to the treatment

Facials consultation card

Multi-line address

Country/Region

Address

City

Zip / Postal code

Pleases leave instructions for parking. FREE immediate parking is required

Birthday

Month

Day

Year

Heart condition

Yes

if Yes, elaborate more

High or low blood pressure

Yes

if Yes, elaborate more

Have you ever used Acne medications?

Yes

if Yes, elaborate more

Have you ever had chemical peels, laser or microdermabrasion?

Yes

if Yes, elaborate more

Loss of skin sensation

Yes

if yes, elaborate more

if Yes, elaborate more

Do you use Retin-A, Retinova, AHA or Retinol products?

Yes

if Yes, elaborate more

Recent scars or surgeries under 6 months

Yes

if Yes, elaborate more

Skin disorders

Yes

if Yes, elaborate more

During chemotherapy or radiotherapy?

Yes

if Yes, elaborate more

What skin brands and routine you follow

What areas of concern do you have regarding your skin?

Breakouts/Acne

Blackheads/Whiteheads

Excessive Oil/ Shine

if Yes, elaborate more

Please upload Doctors notes, if you got medical condition or need adaptation to your treatment or upload proof for parking

Upload your file

Choose a file or drag and drop one here.

I agree with terms and conditions and information given is true

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

I agree to inform immediately, if my body temperature is getting higher than 37 °C, develop cough or loose my sense of teste and smell in the last 24 hrs prior to the treatment