SKIN CONSULTATION FORM Name * First Name Last Name Date of Birth * MM DD YYYY Email * Mobile Phone * Suburb * SKIN PREPARATION & MEDICAL HISTORY Skin Type * Dry Skin Oily Skin Combination Skin Sensitive Skin Not Sure What is your daily skin routine? * Cleanser Exfoliate/Scrub Toner Active Serums Moisturizer/Face oil Sunscreen Face mask Eye cream Lip balm What are your skin main concerns? * Redness/Sensitivity Pigmentation/Sun Damage Acne/Acne Scarring Aging/Wrinkles Others Do any of these apply to me? Pregnant / Breastfeeding Auto Immune Diseases Epilepsy/Seizure Haemophilia / Bleeding Disorders Keloid Scarring Hepatitis HIV/AIDS Accutane / Isotretinoin ( acne medication) Doctor Prescribed Retinol (Vitamin A cream) Active Eczema or Psoriasis or Rosacea (face) Life Threatening/Skin Allergies Recent Minor/Major Surgeries (Last 3 months) Had any of these treatments within 21 days? Botox/Fillers Skin/Laser Treatments Waxing/Threading Major Facial Surgery Any medications and supplements you taking? * MARKETING I understand photos/video are necessary to document the treatment process . From time to time we may use these to educate or promotional purposes. * I AGREE How did you hear about us? * Instagram Facebook Google Youtube Word of mouth Groupon Other STOP!!!! DO NOT Submit. Please allow your technician to review your consent form. Technician has evaluated your form and answered ALL questions * YES NO Technicians Name * Thank you for choosing Refresh Cosmetics!
