G-979687
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15 Childsbridge Lane,
15 Childsbridge Lane . Kemsing . Sevenoaks . Kent .TN15 6TJ
Phone
07960 931136
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Transform Your Skin
Dermaplaning Consultation Form
First name
Last name
D.O.B
Could you be/are you pregnant or lactating
Yes
No
SkinType
Normal
Dry/Dehydrated
Comnination
Sensitive
Ageing
Please give description if you have selected combination skin
Skin Concerns
Acne
Break Outs
Black Heads
Large Pores
Pigmentation
Roseacea
Scaring
Please select any treatmens you have previously had
Fillers
Botox
Lazer treatment
Semi permanent makeup
Skin peels/microdermabrasion
Microcurrent facials
Microneedling
Other
If you have had any of the above treatments, or other treatments not listed above please state when.
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.
How does your skin heal?
Fast
Pigments
Slow
Have you had any surgery
Yes
No
If yes please give details below of what surgery and when you had surgery
Do you have any allegies/gluten intolorant
Yes
No
If yes please state below
Please select any conditios below that apply to you
Skin Cancer (now of previously)
Keloid or Family History of Keloid
Uncontrolled Diabetes
Hemophillia
Hormonal Imbalance
Recent Waxing/Hair Removal
HIV AIDS
Psoriasis
Ezema/Dermatitis
Undergoing Chemotherapy or Radiation
Scleroderma
Recent Sunbed Use Or Sunburn
Active Acne
Raised Lesions
Hepatitis A/B/C
Blood Thinners / Asprin
Lupus / Autoimmune Disease
Blood Clot Disorder
Circulation Disorder
Telangiectasia/Erythema
Are you taking any medications that is related to cosmetic or skin improvement
Yes
No
If yes please state medication below
What skin care products are you currently using and how frequently?
I confirm I have read the acknowledgment above and all of the information I have provided is correct.
Your Signature
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Submit
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