G-979687

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15 Childsbridge Lane . Kemsing . Sevenoaks . Kent .TN15 6TJ

07960 931136

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Taking Care of Your Skin

CACI Consultation Form

First name

Last name

Phone

D.O.B

Skin Type

Normal

Dry/Dehydrated

Oily

Combination

Sensitive

Ageing

Skin Concerns

Acne

Break Outs

Black Heads

Large Pores

Pigmentation

Roseacea

Scaring

Please give description if you have selected combination skin

Please select any treatmens you have previously had

Fillers

Botox

Lazer treatment

Semi permanent makeup

Skin peels/microdermabrasion

Microcurrent facials

Dermaplaning

Microneedling

Other

If you have selected any of the above, please state when you had the treatment

Are you useing any of the following

Retinols

Benzolyl

Alpha hydroxy acids

If you have selected any of the above, when was it last used

Do you have any allegies/gluten intolorant

Yes

If yes please state allergies below

Please tick any of the below that apply to you

Aesthetic Treatments

Anti-depressants

Asthma/Breathing

Epilepsy

Cancer (any form)

Headaches/Migraine

Diabetes

Heart Condition

High/Low Blood Pressure

Highly Sensitive/Delicate Skin

Hormone Irregluatrities

HRT

IBS or other Bowel Conditions

Kidney Infection/Condions

Surgery

Metal Impland (inc IUD)

Multiple Sclerosis

Moles

Under/Over Active Thyroid

Pacemaker

Pregnancey/Lactiating

Prosthesis/Silicone Implant

Recent Operations

Semi Permanent Make Up

Sever/Active Acne

Sever Muscle Conditions

Skin Disorders

Skin Lesions Cuts/Burns

Thrombosis/Phlebitis

Tumours

Varicose Veins

Skin Tags

Seborrhea

Sun Exposure

What skin care products are you using and. how frequently?

I confirm I have read the acknowledgment above and all of the information I have provided is correct.

Your Signature

Opening Hours

Monday.......................... 9.00-19.00
Tuesday.......................... 9.00-19.00
Wednesday................... 9.00-19.00
Thursday....................... 9,00-19.00
Friday ............................ 9.00-18.30
Saturday.........................10.00-16.00
Sunday...........................10.00-16.00

15 Childsbridge Lane
Kemsing
Sevenoaks
Kent
TN15 6TJ

07960 931130

Thanks for submitting!

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15 Childsbridge Lane . Kemsing . Sevenoaks . Kent .TN15 6TJ

07960 931136

CACI Consultation Form

15 Childsbridge Lane Kemsing Sevenoaks Kent TN15 6TJ 07960 931130

15 Childsbridge Lane
Kemsing
Sevenoaks
Kent
TN15 6TJ

07960 931130