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Please fill in this whole consultation and TEXT The Beauty Spot to confirm submission.

CHEMICAL PEEL CONSULTATION FORM
Have you had a Chemical Peel before?

MEDICAL INFORMATION

1) Are you Pregnant?
1) Are you Breastfeeding?
3) Are you currently seeing a Doctor or Clinic?
4) Are you taking any medications or suppliments?
5) Do you Bleed/Bruise easily?
6) Are you receiving Treatment for any medical condition? or have you in the past?
7) Do you suffer from Haemophilia?
9) Have you had any sugery recently?
10) Are you undergoing any Dental Procedures?
11) Do you Suffer from Herpes Simplex? (Cold Sores)
12) Do you suffer with Rosacea?
13) Do you suffer from Keloid or Hypertrophic Scarring?
14) Do you suspect or have you been diagnosed with HIV or AIDS?
15) In the last 6 weeks have you undergone any Chemical, Mechanical or Laser Resurfacing?
16) Are you on holiday within the next 2 weeks?
17) Do you suffer from Hepatitis
18) Do you suffer from any Skin Conditions?
19) Have you ever had any recent facial surgery, aestehtic treatments, injectables/botox, PDO Threads, Aaesthethic Dental Work, Tattoos, piercings?
20) Are you currently receiving Chemotheraphy or Radio Therapy?
21) Are you prone to fainting?
22) Do you suffer from Seborrhoera?
23) Are you on any blood thinning Medication?
24) Have you had Electrolysis, depilatory creams or waxing on the area to be treated?
25) Have you had any sunburn, windburn, cuts or skin abrasions?
26) Do you smoke?
27) Do you suffer from severe or active acne?
28) Do you have any form of skin cancers?
29) Have you taken any medications for acne such as oral retiniods (roaccutane) or benzoyl peroxide in the last 6 months?
30) Do you have predisposition to keliod or hypertrophic scars?
31) Have you used any products containing topical reiniods? (vitamin A, Retinol, Retin A etc) In the last 2 weeks?
32) Are there any aspects of your health that you have no mentioned or been asked that you think The Beauty Spot should be aware of?
fitzpatric scale
33) Looking at the Fitzpatric scale, what Skin Type are you? If you are Fitzpatric 5/6 - TYPEV/ TYPE VI you cannot have Pure or Refresh Peel.
By submitting this form, you declare you have answered all the questions above truthfully and to the best of your knowledge. You are also agreeing to inform The Beauty Spot of any changes to your Medical information, Medications/Surgeries etc before each appointment.
 
You will be asked to also confirm that nothing has changed medically with you since filling out this form, submitting and having the treatment. You MUST inform The Beauty Spot if any changes to your medical history are made.
 

Thanks for submitting your form!

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