Consultation Intake Form Consultation FormΔ First NameLast Name Date of BirthAddressHomeMobileEmergency ContactEmail addressWould you like to receive our special offer by email? Yes NoHow did you hear about us?Treatment area and any concerns you may have:PreviousNext1. General InformationPlease describe any previous treatments you have had and any problems with those treatments:Are you over the age of 18? Yes NoHave you had sun exposure, solarium or spray tan in the last 4 weeks? Yes NoDo you apply sunscreen everyday? Yes NoWhat 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 consumptionPreviousNext2. Medical HistoryAre you currently receiving medical treatment, or have you received treatment within the last six months? Yes NoPlease 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 NoPlease 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 NoPlease provide more details.Have you ever had an allergic reaction to local or topical anaesthetics such as benzocaine, lidocaine, tetracaine, or epinephrine? Yes NoPlease provide more details.Have you ever used or been prescribed topical or oral medications for acne, such as Roacutane? Yes NoPlease provide more details.Have you ever experienced or been treated with or for the following? Contraindications: Any form of epilepsy or seizure disorder Yes NoRespiratory conditions such as asthma Yes NoHigh or low blood pressure Yes NoCardiovascular disorders Yes NoPacemaker/heart condition Yes NoAuto-immune disorders Yes NoSurgery in the treatment area Yes NoMalignant cancer Yes NoEczema or dermatitis Yes NoScleloderma (hardening of the skin) Yes NoKeloid (overgrown fibrous tissue) Yes NoHistory of herpes simplex Yes NoIf 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 NoDo you have any prosthetic implants or any plates or pins in the treatment area? Yes NoIf yes, please provide more details.Have you had laser eye surgery within the past three months? Yes NoDo you suffer from any visual impairments? Yes NoHave you recently experienced a corneal abrasion or retinal detachment? Yes NoHave you been diagnosed with glaucoma, cataracts, dry eye, styes, conjunctivitis, or requent eye infections? Yes NoPlease provide more details.PreviousNext3. Cosmetic HistoryHow 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 poresPlease list and name all current skincare products you are using. Cleanser Toner Serums Moisturiser Sunscreen Make upPlease enter the name of the products you are using.Are you satisfied with your skin care regimen? Yes NoIf 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 Otherplease provide more details and include dates.Please specify.Were you satisfied with the outcome of your treatment? Yes NoPlease explain why?Are you planning to have any of the above treatments in the near future? Yes NoPlease 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 NoClient full nameDateSign below Sign Here PreviousNext4. 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 nameDateSign below Sign Here Previous Submit Form
