Cosmetic Consultation Form

Personal Details
Name *
Name
Address *
Address
Date of Birth
Date of Birth
How did you hear about us?
Please provide details of referral.
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Current Skin Concerns
Please provide details of any current skin concerns you may have.
Have you had any treatments for your skin in the past?
Please include details.
What was the date of your last treatment?
Please advise any issues you've experienced with treatments, if any.
What skincare products are you using?
Please include details of how and when you use these products.
Skin Exacerbation
Are there times when your skin is exacerbated? Provide details below.
Skin Exacerbation Details
Have you used solariums?
Do you wear fake tan?
Medical History
Do you have any allergies or previous reactions to products or treatments?
Please list any past or present illnesses or medical conditions.
Medication
Please provide details of medication you are taking and how long you have been taking it.
Do you have irregular periods?
Do you have a history of any autoimmune disease?
Do you have a history of oral herpes or cold sores?
Do you have any implant/injectables/permanent make up?
Do you have a sun sensitivity disorder? (eg. Lupus)
Do you have any past skin history of: eczema, rosacea, skin sensitivity?
If yes, please list areas.
Have you had a previous reaction to tropical anaesthetic or local anaesthetic?
If yes, please list areas.
Are you pregnant/breast feeding?
Are you prone to Keloids or hypertrophic scars?
Informed Consent *
At Skindepth Dermatology we have a commitment to ensuring that our patients are informed about their financial obligations. All fees involved are to be paid on the day of the consultation. I CERTIFY that I fully understand the terms and conditions surrounding my consent with Skindepth Dermatology.