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    LED-Face-Mask-Consultation-Form - 2

    Uploaded by

    Hanan Ansari
    ........................................................................................ Date: ...........................................................

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    LED-Face-Mask-Consultation-Form - 2

    Uploaded by

    Hanan Ansari
    49 views2 pages
    ........................................................................................ Date: ...........................................................

    Original Description:

    aesthetic consultation

    Original Title

    LED-Face-Mask-Consultation-Form- 2

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    ........................................................................................ Date: ...........................................................

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    49 views2 pages

    LED-Face-Mask-Consultation-Form - 2

    Uploaded by

    Hanan Ansari
    ........................................................................................ Date: ...........................................................

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    LED FACE MASK CONSULTATION FORM

    Name Date of Consultation

    Address:

    Tel No: Mobile:

    Date of Birth Occupation


    Email:
    Doctors Name &
    Address

    Do any of the following apply to you:


    Epileptic Pregnant Cancer
    Thyroid problems Lupus Anxiety
    Depression Diabetes Heart problems
    High blood pressure Acne Cancer
    Recent facial surgery (in last Bacterial infection Fungal infection
    3 months)
    Taking or recently taken Eczema/Psoriasis/
    Roaccutane (in last 12 Dermatitis
    months)
    IF TICKED YES TO ANY OF THE ABOVE, WRITE IN FURTHER INFORMATION BELOW

    Are you taking any of the following drugs:


    Anti-anxiety drugs (e.g. Antibacterial drugs (e.g. Antibiotics (quinolones,
    alprazolam, chlorhexidine, sulphonamides,
    chloridiazepoxide) hexachlorophene) tetracyclines,
    trimeothoprim)
    Antidepressants (e.g. Anti-fungals (e.g. Anti-hyperglycaemic
    tricyclics) griseofulvin) drugs (sulfonylureas)
    Anti-malarials (e.g. Anti-psychotics (e.g. Diuretics (e.g. frusemide,
    chloroquine, quinine) phenothiazines) thiazides)
    Heart drugs (e.g. Acne drugs (isotretinoin) Lithium
    amiodarone, quinidine)
    Melatonin Methotrexate Steroids/cortisone
    Phenothiazine
    What other prescription medication are you taking?
    Do you have any other relevant conditions not mentioned above?

    Why have you come for an LED Facial Treatment?

    ESTABLISH AREAS OF CONCERN:

    Client declaration: I confirm that to the best of my knowledge the answers that I have given are correct and I
    have not withheld any information that may be relevant to my treatment. I have been informed about the
    expected results and effects of the treatment and agree to follow all aftercare advice provided to me by my
    therapist.

    Signed: ………………………………………………………………………………. Date: ……………………………………………………..

    Therapist: …………………………………………………………………………… Date: …………………………………………………..

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