Live example - nothing you submit is saved.Back to the template

Facial Treatment Consent

Please complete before your facial so we can choose the right treatment for your skin.

Full name* (required)Date of birth* (required)Email address* (required)Which treatment?* (required)

Your skin

Skin type* (required)

What would you like to address?* (required)

Congestion or breakouts Pigmentation Fine lines Redness or rosacea Dryness Dullness Texture Large pores General maintenance

What do you use at home?* (required)

Are you using any of these?* (required)

A prescription retinoid - tretinoin or adapalene Over-the-counter retinol Glycolic, lactic or salicylic acid Vitamin C serum Benzoyl peroxide Hydroquinone or skin lightening None of these

If you use actives, when did you last apply them?* (required)

Recent treatments and health

In the last month, have you had any of these?* (required)

A chemical peel Microneedling Laser or IPL Botox Dermal filler Waxing on the face Sunbathing or a sunbed None of these

Have you taken isotretinoin (Roaccutane) in the last 12 months?* (required)

Do any of these apply?* (required)

Cold sores Eczema or psoriasis Rosacea Keloid scarring Autoimmune condition Currently pregnant Diabetes None of these

Allergies* (required)Medication

Confirmations

I understand redness, sensitivity, purging or temporary pigment change are possible* (required)

I will follow the aftercare given, including sun protection* (required)

I understand results vary and more than one session may be needed* (required)

The information above is accurate* (required)

Leave this field empty