FACIAL TREATMENT

Quick Intake & Consent Form

All information is confidential.

1. CLIENT DETAILS

Full Name

Phone

Email

Date of Birth
Format: DD/MM/YY (e.g. 25/12/95)

2. TREATMENT TYPE (SELECT ONE OR MORE)

Deep Facial CleansingMini Skincare FacialFace Lift MassageFace & Neck Massage

3. SKIN TYPE (SELECT ONE)

NormalDryOilyCombinationSensitive

4. SKIN CONDITIONS (CHECK ALL THAT APPLY)

Acne / breakoutsBlackheads / congestionDehydrationRedness / rosaceaPigmentationFine lines / wrinklesSensitive or reactive skinEczema / psoriasisOpen wounds / active infection

Other skin condition

5. MEDICAL & SKIN HISTORY

Are you currently under dermatological treatment?
YesNo

Have you had a facial treatment in the last 2 weeks?
YesNo

Do you have any allergies or sensitivities (products, fragrances, latex)?

Current medication or topical products (e.g. retinoids, acids)

6. CONTRAINDICATIONS (LAST 7–14 DAYS)

Retinol / Vitamin AChemical peelLaser / IPLInjectable treatments (Botox / fillers)Oral isotretinoin (Roaccutane)None of the above

7. FACIAL MASSAGE & PRESSURE PREFERENCE

(If facial massage is included)

Very gentleModerateFirm (within safe facial limits)

Areas to avoid (if any)

Please indicate how you were referred to our clinic.

Google SearchSocial MediaReferral from Friend or FamilyOnline ReviewsExisting / Returning ClientWalk-inOther

9. DATA | COMMUNICATION CONSENT (GDPR) | ACKNOWLEDGEMENT

I confirm that the information provided is accurate and I consent to receive facial treatment. I understand this is not a substitute for medical or dermatological care.
I consent to the collection and storage of my personal data for treatment, record-keeping, and billing purposes.

I agree to receive appointment reminders and clinic communications.

I agree to receive promotional offers and updates (optional).

Signature (Type Full Name)

Date