G-979687
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15 Childsbridge Lane,
15 Childsbridge Lane . Kemsing . Sevenoaks . Kent .TN15 6TJ
Phone
07960 931130
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CACI Consultation Form
First name
Last name
Email
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
No
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.
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