Profhilo Consultation Form

(Reading)

First Name *

Last Name

Phone *

Date of birth (DD-MM-YYYY) *

Gender *

Male

Female

Other

Email *

Address

Street Address *

City *

State *

Postal code *

Body Area(s) (Please state body area(s) you are having treatment on

Medical History

Is there any chance you could be pregnant/Breastfeeding?

Yes

Have you a history of severe allergy or anaphylaxis?

Are you currently receiving any medical treatment?

Have you previously received any aesthetic treatments (e.glaser, peels, dermabrasion etc)?

Have you had any treatment with dermal fillers, absorbabledermal fillers, semi-permanent dermal fillers or botulinumtoxin?

Have you ever suffered from auto-immune disease or disease affecting the immune system?

Do you suffer from any allergies, in particular allergies tohyaluronic acid, amide type local anaesthetics or lidocaine?

Do you suffer from untreated epilepsy?

Do you suffer from porphyria?

Do you suffer from cardiac conduction disorders?

Other

What are your goals/expectations for the treatment?

Please indicate how your skin responds to midday summer sun exposure with no sunscreen:

Skin Type 1 - Always burn, never tans

Skin Type 2 - Easily burnt, eventually gets a moderate tan

Skin Type 3 - Sometimes burns, quickly gets a deep tan

Skin Type 4 - Rarely burns, quickly gets a deep tan

Skin Type 5 - Very rarely burns, consistent tan

Skin Type 6 - Never burns, consistent tan

Pre Treatment Check List

To be completed by Reception / Operator. Tick to confirm points have been discussed

Consent for Profhilo Treatment

Consent

Please provide additional information or if there is anything else you think should be brought to the therapist’s attention !
To avoid these possibility of there being any contra- indications arising from the treatment(s) you are having with us, it is important that you fully disclose now and in the future (by completing a new form) any such medical information. Always consult your doctor first about any concerns you may have about your health. In certain cases written permission will be required either by your GP/Specialist or Personal Disclaimer prior to any treatments being conducted.
I confirm that I have not withheld any information regarding any medical conditions or problems that I may be experiencing and that I have provided details of all medication I am currently taking.

Signature *

Our aim to provide incredible results in affordable prices.

Additional Comment