Skin Consultation Form | Exposehairandbeauty

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Skin Consultation form for Coolite Hair removal and Skin Rejuvenation laser treatments.

Please note a compulsory patch test must be carried out at least 48 hrs beforehand for laser hair removal.Please contact the salon directly to book your patch test appointment.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone *

D.O.B *

GP Details

GP Name *

GP Phone Number *

Do you suffer from any of the following conditions

Any skin conditions being treated by a Dermatologist? *

Yes
No

Medical Odema *

Yes
No

Osteoporosis *

Yes
No

Arthritis *

Yes
No

Recent operations *

Yes
No

Diabetes *

Yes
No

Asthma *

Yes
No

Bells Palsy *

Yes
No

Inflamed nerves of the face *

Yes
No

Acute Rheumatism *

Yes
No

Autoimmune disease *

Yes
No

Please note if you suffer from any of the above conditions you must get a letter from your doctor clearing you for treatment.

Contraindications

The following contraindications may restrict treatment please answer yes or no to the following

Fever *

Yes
No

Contagious diseases *

Yes
No

Cancer *

Yes
No

Pregnancy *

Yes
No

Breastfeeding *

Yes
No

Any drugs or medication that may thin the skin *

Yes
No

Contraceptive pill *

Yes
No

Epilepsy *

Yes
No

Any heart conditions *

Yes
No

Are you taking any blood thinners *

Yes
No

Herpes (cold sore virus) *

Yes
No

Recent sunburn *

Yes
No

False tan application in the last 2 weeks *

Yes
No

Melasma, Vitiligo or dark Moles *

Yes
No

Any metal pins or plates *

Yes
No

Loss of skin sensitivity *

Yes
No

Have you used any Vit A products for eg retinoids in the last 2 weeks *

Yes
No

Have you been on antibiotics or steroids in the last 2 weeks *

Yes
No

Have you had any botox or fillers in the last 2 weeks *

Yes
No

Have you had any IPL, Laser or Peels in the last 4 weeks *

Yes
No

Any other medical conditions that we should be aware of?

Only applicable for hair removal

Have you had any other forms of hair removal in the last 6 weeks?

Yes
No

For example: waxing, threading or plucking?

face diseases weeks

Signature *

Clear Signature

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