SKIN TREATMENT CONSULTATION FORM

[uacf7-row]

[uacf7-col col:6]

Todays Date (required)

[/uacf7-col]

[uacf7-col col:6]

Your Name and Surname (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:3]

Your Email (required)

[/uacf7-col]

[uacf7-col col:3]

Mobile Number (required)

[/uacf7-col]

[uacf7-col col:3]

Telephone

[/uacf7-col]

[uacf7-col col:3]

Your Address (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:4]

Your DOB (required)

[/uacf7-col]

[uacf7-col col:4]

Your Age? (required)

[/uacf7-col]

[uacf7-col col:4]

Your GP's Address (required)

[/uacf7-col]

[/uacf7-row]

What skin treatment are you interested in having?

[uacf7-row]

[uacf7-col col:4]

Treatment Type (required)

[/uacf7-col]

[uacf7-col col:4]

What are you primary concerns you wish to be treated?(required)

[/uacf7-col]

[uacf7-col col:4]

Do you have any known allergies? (E.G Latex, metals, shellfish, nuts, penicillin) (required)

[/uacf7-col]

[/uacf7-row]

Are you currently experiencing any of the following active skin conditions?

[uacf7-row]

[uacf7-col col:3]

Papulopustular Rosacea (required)

[/uacf7-col]

[uacf7-col col:3]

Herpes Simplex (required)

[/uacf7-col]

[uacf7-col col:3]

Scleroderma (required)

[/uacf7-col]

[uacf7-col col:3]

Open Lesions (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:3]

Skin Cancer (required)

[/uacf7-col]

[uacf7-col col:3]

Acne vulgaris stage III-IV (required)

[/uacf7-col]

[uacf7-col col:3]

Warts (required)

[/uacf7-col]

[uacf7-col col:3]

Bacterial / Fungal infections (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:6]

Solar Keratosis (required)

[/uacf7-col]

[uacf7-col col:6]

Have you ever experienced any adverse reaction to any form of anaesthetic?(required)

[/uacf7-col]

[/uacf7-row]

Are you currently under medical supervision for any of the following?

[uacf7-row]

[uacf7-col col:3]

Cardiac conditions(required)

[/uacf7-col]

[uacf7-col col:3]

Auto-immune disorder (required)

[/uacf7-col]

[uacf7-col col:3]

Haemophilia (required)

[/uacf7-col]

[uacf7-col col:3]

Open Lesions (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:3]

Hepatic diseaserequired)

[/uacf7-col]

[uacf7-col col:3]

Diabetes (Type I or II) (required)

[/uacf7-col]

[uacf7-col col:3]

Cancer (required)

[/uacf7-col]

[uacf7-col col:3]

Human Immunodeficiency Virus (HIV) (required)

[/uacf7-col]

[/uacf7-row]

Are you currently taking (or have taken in the last 3 months) any of the following medications or supplements?

[uacf7-row]

[uacf7-col col:3]

Isotretinoin (including but not limited to Roaccutane / Accutane / Isotane) (required)

[/uacf7-col]

[uacf7-col col:3]

Anti-coagulants / blood thinners (including but not limited to Warfarin or aspirin) (required)

[/uacf7-col]

[uacf7-col col:3]

Photo-sensitisers (including but not limited to Anti-depressants / anti-anxieties / antibiotics)(required)

[/uacf7-col]

[uacf7-col col:3]

Contraceptive Pill (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:4]

Fish oils / Plant oils / Omega 3’s (required)

[/uacf7-col]

[uacf7-col col:4]

Ginseng / Gingko biloba / St Johns Wort (required)

[/uacf7-col]

[uacf7-col col:4]

Are you currently pregnant or breastfeeding?

[/uacf7-col]

[/uacf7-row]

Have you had any of the following procedures in the last 3 months on the area to be treated with Dermapen™?

[uacf7-row]

[uacf7-col col:3]

Plastic / Cosmetic Surgery (required)

[/uacf7-col]

[uacf7-col col:3]

Muscle relaxant injections (including but not limited to Botox or Dysport) (required)

[/uacf7-col]

[uacf7-col col:3]

Dermal Fillers (including but not limited to JuvDerm, Restylane, Esthelis, Radiesse, Aquamid, Sculptra or Artefill)(required)

[/uacf7-col]

[uacf7-col col:3]

Laser / IPL Rejuvenation / Hair Removal (required)

[/uacf7-col]

[/uacf7-row]

[uacf7-row]

[uacf7-col col:3]

Photo dynamic therapy (PDT) (required)

[/uacf7-col]

[uacf7-col col:3]

Dermabrasion (required)

[/uacf7-col]

[uacf7-col col:3]

Deep Chemical Peel(required)

[/uacf7-col]

[uacf7-col col:3]

Tattooing / permanent make-up (required)

[/uacf7-col]

[/uacf7-row]

I,: have completed the Skin Treatment clinical treatment consultation form honestly and to the best of my knowledge, and understand the treatment, how it works and expected outcomes.
I understand a course of treatment may be required for optimum results.

Print you full Name:

Sign in the Box:

Are You Human?

Terms and Conditions

We want you to know how our service works and why and how we handle your data. Please state that you have read and agreed to these terms and conditions.

I Agree to theTerms and Conditions

Please leave this field empty.

Contact Permission

Occasionally we would like to newsletters and offers and the latest info from Sunnyside Skin Clinic by Email, post, SMS and other electronic means. We take your privacy very seriously and will only use your personal infomrmation to administer your account and to provide the services you have requested from us. If you consent to us contacting you for this purpose please tick to say how you would like us to contact you.
PostEmailTelephoneSMS

[wpgdprc "By using this form you agree with the storage and handling of your data by this website."]

Cart

Cart