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Jan Marini

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First name

Last name

Phone

What are your primary skin concerns that you wish to be treated?*

Do you have any known allergies? (e.g. latex, metals, shellfish, nuts)*

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

Rosacea

Herpes Simplex

Bacterial/fungal infections

Skin cancer

Eczema

Vitiligo

Acne

Warts

Open cuts/wounds

Psoriasis

Undiagnosed/unusual moles

Keloid scars

Other

None of the above

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

Cardiac conditions

Hepatic disease

Diabetes (type 1 or 2)

Cancer

Auto-immune disorder

Human Immunodeficiency Virus (HIV)

None of the above

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

Isotretinoin (inc. Roccutane, Accutane, Isotane)

Anti-coagulants/blood thinners

Fish oils/Plant oils/Omega 3's

Contraceptive pill

Photosensitisers

None of the above

Have you had any of the following procedures in the last 2 weeks?*

Plastic/cosmetic surgery

Botox/fillers

Dermaplaning

Microdermabrasion

Laser/IPL

Tattooing/cosmetic tattooing

Electrolysis

Radio frequency

Photo dynamic therapy

Chemical peel

Dermabrasion

Hair removal

Spray/self tanning/sunbeds

None of the above

Have you used any products containing any of the following ingredients in the last week?*

Bleaching agents

Antimicrobial agents

Resurfacing agents(e.g. Salicylic acid, Alpha-hydroxy acids, Beta-hydroxy acids)

Retinoids (Inc. Tretinoin, Adapalene, Retinol)

None of the above

Client Signature*

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I confirm that the information i have provided is accurate and complete. I understand that i must inform my therapist of any changes to my medical or skin conditions before treatment.

Have you looked at our treatment list?

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TERMS & CONDITIONS

thebeauteshed@hotmail.com

01963 440802

Unit 3 The Stalls, Newhouse Farm, Cole Street Lane, Madjeston, Gillingham, Dorset SP8 5JQ

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Jan Marini

Subscribe to The Beauté Shed Newsletter Join our mailing list for the latest shedling news!

Subscribe to The Beauté Shed Newsletter
Join our mailing list for the latest shedling news!