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Chloe's Annex
Skin Treatments & Massage
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First name
Address
Post Code
Phone Number
Emergency Contact Name
Last name
Address
D.O.B
Email
Emergency Number
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 this 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 below
Please tick any of the below that apply to you
Electrical implements in the body (e.g. pacemaker)
Hearing aid
Metal pins/plates
Heart conditions
Cancer
Diabetes
Psychological discorders
Migranes
Hormonal disorders
Blood disorders (Anaemia, leucosis/leukaemia, haemophillia
Cuts, abrasions, bruises
Serious vasular disorders (thrombosphlebitis etc)
High Blood Pressure
Epilepsy
Contagious diseases/infection
Hyperthyroidism
Endocrine disorders (pheochromocytoma etc)
Hepatitis or renal insufficiency
Pregnancy
Heat sensitivity
Rosacea or excesive dilated capillaries
Sever/Active Acne
Skin Disorders
Seborrhea
Recent sun exposure/sunbeds
Do you have any other health condition which are not listed above? If yes please give details in the space provided.
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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