Consultation

Skino

Consultation Form

First name

Last name

Phone

Birthday

Medical History

Currently receiving any treatment from a doctor or specialist? If yes, please explain

Taking any medication, supplements or herbal remedies? If yes, please explain

Allergic to medications, antibiotics, foods or other substances? If yes, please explain

Had any previous surgery or been admitted to hospital? If yes, please explain

Currently pregnant or breastfeeding?

Yes

Suffer from any allergies? If yes, please explain

Ever had an allergic reaction to any beauty treatment, products, including injectable? If yes, please explain

Suffer from Myasthenia Gravis or Eaton Lambert syndrome? If yes, please explain

Any other aspect of your health that we should know about? If yes, please explain

Treatment History

Any form of cosmetic treatment e.g. botulinum toxin, dermal fillers, rhinoplasty? If yes, please enter all

Previously received any aesthetic treatments(e.g. laser, peels, dermabrasion etc.), If yes, please enter all

Your routine

Drinking alcohol? If yes, how often?

Smoking? If yes, how often?

Regular exercise? If yes, how frequent?

Describe your skin care routine

Your Signature

Aesthetician Notes

Thank you for considering Skino for your aesthetic needs. We have received your information and will be in touch shortly to discuss your options and schedule a consultation.