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The Beauty SPOT
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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?
*
YES
NO
If YES, please state how your experience was below
Why are you getting the Chemical Peel? What area would you like targeting most?
MEDICAL INFORMATION
1) Are you Pregnant?
*
YES
NO
1) If you answered YES, How many weeks pregnant are you?
1) Are you Breastfeeding?
*
YES
NO
2) Do you suffer from any allergies, allergies to Latex, or fruit acids? if YES, Please state further
3) Are you currently seeing a Doctor or Clinic?
*
YES
NO
3) If YES, Please explain in further details below
4) Are you taking any medications or suppliments?
*
YES
NO
4) If YES, Please explain in further details below
5) Do you Bleed/Bruise easily?
*
YES
NO
6) Are you receiving Treatment for any medical condition? or have you in the past?
*
YES
NO
6) If YES, Please explain in further detail below
7) Do you suffer from Haemophilia?
*
YES
NO
8) If you are on any anti-biotics please list below
9) Have you had any sugery recently?
*
YES
NO
9) If YES, Please explain further
10) Are you undergoing any Dental Procedures?
*
YES
NO
10) If YES, Please explain further
11) Do you Suffer from Herpes Simplex? (Cold Sores)
*
YES
NO
12) Do you suffer with Rosacea?
*
YES
NO
13) Do you suffer from Keloid or Hypertrophic Scarring?
*
YES
NO
13) If YES, Please explain further
14) Do you suspect or have you been diagnosed with HIV or AIDS?
*
YES
NO
15) In the last 6 weeks have you undergone any Chemical, Mechanical or Laser Resurfacing?
*
YES
NO
15) If YES, Please explain further
16) Are you on holiday within the next 2 weeks?
*
YES
NO
17) Do you suffer from Hepatitis
*
YES
NO
18) Do you suffer from any Skin Conditions?
*
YES
NO
18) If YES, Please explain further
19) Have you ever had any recent facial surgery, aestehtic treatments, injectables/botox, PDO Threads, Aaesthethic Dental Work, Tattoos, piercings?
*
YES
NO
19) If YES, Please explain further
20) Are you currently receiving Chemotheraphy or Radio Therapy?
*
YES
NO
20) If YES, Please explain further
21) Are you prone to fainting?
*
YES
NO
22) Do you suffer from Seborrhoera?
*
YES
NO
23) Are you on any blood thinning Medication?
*
YES
NO
23) If YES, Please explain further
24) Have you had Electrolysis, depilatory creams or waxing on the area to be treated?
*
YES
NO
24) If YES, Please explain further
25) Have you had any sunburn, windburn, cuts or skin abrasions?
*
YES
NO
26) Do you smoke?
*
YES
NO
27) Do you suffer from severe or active acne?
*
YES
NO
28) Do you have any form of skin cancers?
*
YES
NO
28) If YES, Please explain further
29) Have you taken any medications for acne such as oral retiniods (roaccutane) or benzoyl peroxide in the last 6 months?
*
YES
NO
29) If YES, Please explain further
30) Do you have predisposition to keliod or hypertrophic scars?
*
YES
NO
31) Have you used any products containing topical reiniods? (vitamin A, Retinol, Retin A etc) In the last 2 weeks?
*
YES
NO
31) If YES, Please explain further
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?
*
YES
NO
32) If YES, Please explain further
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.
*
TYPE I
TYPE II
TYPE III
TYPE IV
TYPE V
TYPE VI
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.
​
I declare I have filled this form to the best of my knowledge and understand the terms and conditions.
SUBMIT CONSULTATION
Thanks for submitting your form!
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