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Chloe's Annex
Skin Treatments & Massage
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Microneedling Consultation Form
First name
Last name
D.O.B
Could you be/are you pregnant or lactating
Yes
No
Skin Concerns
Acne
Break Outs
Black Heads
Large Pores
Pigmentation
Roseacea
Scaring
Skin Type
Normal
Dry/Dehydrated
Oily
Combination
Sensitive
Ageing
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 please state when in the space provided below.
Are you using any of the products below
Retinols
Benzolyl
Alpha hydroxy acids
If you have selected any of the above, when did you last use it?
How does your skin heal?
Fast
Pigments
Alpha hydroxy acids
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 or are you gluten intolorant
Yes
No
If yes please state allergies below
Please select any conditios below that apply to you
Skin Cancer (now or previously)
Diabetes
Hemophillia
Keloid or family history of keloid
Claustrohobia
HIV AIDS
Psoriasis
Exzema/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
Raised lesions
Recent sunburn or sunbeds
Telangiectasia/erythema
Other
Please disclose any other condtion not listed above
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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