Consultation Form Medix Skincare

Consultation Intake Form

Consultation Form

First Name

Last Name

Date of Birth

Address

Home

Mobile

Emergency Contact

Email address

Would you like to receive our special offer by email?

Yes

How did you hear about us?

Treatment area and any concerns you may have:

1. General Information

Please describe any previous treatments you have had and any problems with those treatments:

Are you over the age of 18?

Yes

Have you had sun exposure, solarium or spray tan in the last 4 weeks?

Yes

Do you apply sunscreen everyday?

Yes

What is your occupation? Do you work inside or outside?

How often do you exercise? inside or outside? what time of the day?

Please tick all applicable boxes.

Pregnant or lactating

Menopause or perimenopausal

Wearing contact lenses

Wearing eyelash extensions

Smoking

Alcohol consumption

2. Medical History

Are you currently receiving medical treatment, or have you received treatment within the last six months?

Yes

Please name your current medications and their intended use.

Please list any medications used within the past six months, their intended use, and their duration.

Are you currently taking any over-the-counter medications or supplements?

Yes

Please name your medications and their intended use.

Are you allergic to any medication, foods, or skin care products, or have you ever experienced allergic reactions of any kind?

Yes

Please provide more details.

Have you ever had an allergic reaction to local or topical anaesthetics such as benzocaine, lidocaine, tetracaine, or epinephrine?

Yes

Please provide more details.

Have you ever used or been prescribed topical or oral medications for acne, such as Roacutane?

Yes

Please provide more details.

Have you ever experienced or been treated with or for the following? Contraindications:

Any form of epilepsy or seizure disorder

Yes

Respiratory conditions such as asthma

Yes

High or low blood pressure

Yes

Cardiovascular disorders

Yes

Pacemaker/heart condition

Yes

Auto-immune disorders

Yes

Surgery in the treatment area

Yes

Malignant cancer

Yes

Eczema or dermatitis

Yes

Scleloderma (hardening of the skin)

Yes

Keloid (overgrown fibrous tissue)

Yes

History of herpes simplex

Yes

If you answered yes to any of the above, please provide more details and include dates.

Are you currently taking any blood-thinning medications, such as aspirin and warfarin?

Yes

Do you have any prosthetic implants or any plates or pins in the treatment area?

Yes

If yes, please provide more details.

Have you had laser eye surgery within the past three months?

Yes

Do you suffer from any visual impairments?

Yes

Have you recently experienced a corneal abrasion or retinal detachment?

Yes

Have you been diagnosed with glaucoma, cataracts, dry eye, styes, conjunctivitis, or requent eye infections?

Yes

Please provide more details.

3. Cosmetic History

How do you feel about the condition of your skin, and how can we help?

What are your top three goals for your skin?

Area to be treated and any concerns you may have:

Skin tags and moles

Lines and wrinkles

Hooded eyelids

Pigmentation/sundamaged skin

Acne or surgery scars

Enlarged pores

Please list and name all current skincare products you are using.

Cleanser

Toner

Serums

Moisturiser

Sunscreen

Make up

Please enter the name of the products you are using.

Are you satisfied with your skin care regimen?

Yes

If not, could you please share why?

Have you had any of the following treatments in the last 3 months?

Chemical peel

Skin needling

Laser treatment

Any kind of surgery

Anti wrinkle injection

Fillers

Permanent makeup

None

Other

please provide more details and include dates.

Please specify.

Were you satisfied with the outcome of your treatment?

Yes

Please explain why?

Are you planning to have any of the above treatments in the near future?

Yes

Please provide more details and include dates.

Are you aware that you may not look your best for a few days following treatment, that there will be some downtime, that you may experience some minor discomfort, redness, and swelling, and that you will be expected to follow an aftercare regimen?

Yes

Client full name

Date

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4. Consent Form

I understand that the treatments provided by Medix Skincare are exclusively elective cosmetic procedures, with no medical claims expressed or implied.
I acknowledge that the treatment results cannot be predicted or guaranteed and that I may require multiple treatments to achieve the desired outcomes.
I confirm that I’m not pregnant and it is my responsibility to inform the esthetician about my health and any medical condition.
I confirm that I’m not currently under the influence of any drugs or alcohol.
I confirm that I don’t have a metal prosthesis, a pacemaker, any skin disease or infection conditions, thrombosis or malignancy, altered sensation, or liver misfunction, and that my health values are within normal limits.
I acknowledge that I may experience temporary discomfort, tightness, redness, and swelling in the treatment area, which may last for a few days depending on the treatment area and my skin condition.
acknowledge that color changes, such as hyperpigmentation (brown or red discoloration), may occur in the treated area following chemical peels, laser, and plasma pen treatments, and that it may take several months or longer for the skin to return to its normal condition.
I acknowledge that mild crusting and peeling of the skin following chemical peels, laser, and plasma pen treatments are normal. Scarring is a rare possibility that may occur in less than 1% of the population.
I acknowledge that I may not look my best for a few days following chemical peels, laser, and plasma pen treatments, that there will be a period of downtime, and that I must adhere to all aftercare recommendations.
I acknowledge that I should avoid hot showers, vigorous exercise, saunas, and swimming pools for at least one week after chemical peels and laser treatments and for four weeks after plasma pen treatments.
I acknowledge that it’s my responsibility to protect my skin from the sun for at least three weeks prior to and after a chemical peel, laser, and plasma pen treatments. Unprotected skin may impact the treatment outcome and the healing process, in addition to causing pigment changes and scarring.
I acknowledge that all my questions have been answered truthfully and completely.
I consent to have my treatment administered by Medix Skincare and Laser Clinic sta and to comply with all pre- and post-treatment instructions.
I consent to photographs for the purpose of monitoring my treatment results.
I hereby give Medix Skincare permission to use my before, during, and after photographs for marketing and social media purposes.

Client full name

Date

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