Full Name *

DOB (DD/MM/YYYY) *

Age *

Street Adress *

City *

Postal / Zip Code *

Email *

Phone *

Have you had a facial treatment before? *

Had any skin problems in the last 4 weeks? *

Do you have any severe skin issues? *

Have you used acids on your skin in the last 5 days? *

Are you on any kind of medication? *

Do you have any allergies? *

Have you suffered an allergic reaction before? *

if Yes(for allergies. please state below.

Are you pregnant? *

Do you have HIV? *

Are you on any kind of medication? *

Do you have asthma/respiratory problems? *

Are you suffering from acne or have you suffered from acne? *

How long have you suffered from acne if so? *

Are you on minocycline or any other acne treatment? *

Do you suffer from PCOS? *

Have you tested positive for COVID-19 in the last 10 days or been in contact? *

Please let me know the outcome you would like from this facial so I can accommodate to my best ability: *

Name *

Phone *

Street Address *

City *

Postal / Zip Code

Skin Type *

Client requirements *

Added notes *

How did you find us? *

Would we be able to feature you on our social media? *

Date & Time of selected appointment *

Beautician

Treatment Selection *

I have read the information and if I have any concerns, I will address these with my beautician. I give permission to my beautician to perform a facial treatment procedure we have discussed, and will not hold her or her staff liable for any adverse reaction to the treatment. I have given an accurate account of the questions asked including all known allergies or prescription drugs or products I am currently ingesting or using. I understand my aesthetician will take every precaution to minimise or eliminate negative reactions as much as possible. Due to the nature of the treatment refunds are not offered, or will be given.

State name *

Date (DD/MM/YYYY) *

we consider all these details ahead of your appointment and. we look forward to seeing you x

we consider all these details ahead of your appointment and. we look forward to seeing you x

Country/region

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