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ADVANCED SKIN CONSULTATION FORM

Please read through all of the contraindications and suitability information below before proceeding with any treatment

Contraindications to Microneedling & Chemical Peels :​

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  • Pregnant / Nursing

  • Active acne

  • Herpes simplex or any other infection such as flat warts

  • Moderate to severe chronic skin disease such as eczema and psoriasis

  • If received any medical grade chemical peel in the last 4 weeks

  • Blood dyscrasias, patients on anticoagulant therapy.

  • Extreme keloidal tendency.

  • Patient on chemo/radiotherapy

  • Haemophilia

  • Blood thinner medications

  • Recent use of glycolic acids, alpha-hydroxy acids

  • Rosacea

  • Skin cancer

  • Sunburn

  • New tattoos in the area

  • Telangiectasia/erythema may be worsened or brought out by exfoliation

  • Uncontrolled Diabetes

  • Vascular Lesions

  • Have open cuts or lesions on the skin

  • Allergies / anaphlaxis

  •  Frequent sunbed user - Pigmentation treatment only

  • Allergic to AHA's

  • Laser Treatments 

  • Keloid Scars

  • Ro-accutane user

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contraindication to dermaplaning

  • Current inflamed acne lesions;

  • Skin cancer;

  • Active cold sores;

  • Uncontrolled diabetes;

  • Dermatitis;

  • Open skin lesions;

  • Use of Accutane currently or in the past six months; and/or.

  • The use of prescription retinol within a week of treatment.

HAVE YOU USED RO-ACCUTANE OR RETIONOL IN THE LAST 6 MONTHS?
HAVE YOU USED AN ACNE MEDICATION?
HAVE YOU USED ANY OF THE FOLLOWING HAIR REMOVAL METHOS IN THE PAST SIX WEEKS? Required
WHAT AREAS OF CONCERN DO YOU HAVE REGARDING YOUR SKIN? Required
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING? Required

GENERAL CONSENT AND PROCEDURE PERMIT

  1. I have accurately described my previous medical history / including any condition and / or complications that might preclude receiving any treatments.

  2. I am 18 years and above.

  3. I am not pregnant or breastfeeding (Okay for Dermaplaning)

  4. I understand and will follow post treatment instructions.

  5. I have had the opportunity to ask any questions and all questions have been answered and understood.

  6. There may be some redness and flushing post treatment, which can last up-to 72 hours post procedure.

  7. There may be some superficial swelling and pain during treatment (Microneedling & Chemical peel)

  8. There may be some pin point bleeding during treatment (Microneedling)

  9. Extreme side effects may include infections (VERY unlikely) 

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I understand that withholding information or providing misinformation may result in contraindications and or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility therefor. 

Thanks for submitting!

NURSE ARLEANA
UNIT 1
93 WHITCHURCH ROAD
SHREWSBURY
SY1 4EQ

THE BODY WORKS CLINIC
31 CHAPEL STREET
SHEPSHED
LOUGHBOROUGH
LEICESTERSHIRE
LE12 9AF

07720247728
AESTHETICSJH@GMAIL.COM

©2020 by Jordan Louise Aesthetics & Training.

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