Aura Consent Forms
Consultation Card
Personal / Contact Details
Name
Please enter Name.
Date of Birth (dd/mm/yyyy)
Please enter/select Date of Birth.
Email Address
Please enter Email Address.
Phone Number
Please enter Phone Number.
Postcode
Please enter Postcode.
Address
Please enter Address.
Therapist
Please enter Therapist.
Please answer these questions to help us provide the best service for your skin.
Your Health
Within the last year, have you had any health problems that have affected or could affect your skin?
Yes
No
Do you take any medications, supplements vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly?
Yes
No
Do you wear contact lenses?
Yes
No
Do you have metal implants a pacemaker or body piercings?
Yes
No
Do you have any allergies?
Yes
No
Do you have sinus problems?
Yes
No
Have you ever experienced claustrophobia?
Yes
No
Your Skin
Have you any specific concerns/challenges with your skin?
Yes
No
Any kind of skin care products are you currently using?
Yes
No
Cleanser
Yes
No
Toner
Yes
No
Exfoliant
Yes
No
Eye Products
Yes
No
Soap
Yes
No
Masque
Yes
No
Moisturiser
Yes
No
Other
Yes
No
Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 3 months?
Yes
No
Have you Been Wax within the last 72 hours?
Yes
No
Have you Shaved within the last 24 hours?
Yes
No
Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last 3 months?
Yes
No
Are you currently using any products that contain the following ingredients?
Yes
No
Glycolic Acid
Yes
No
Lactic Acid
Yes
No
Any exfoliating scrub
Yes
No
Other Hydroxy Acids
Yes
No
Vitamin A derivatives (ie, Retinol)
Yes
No
Please specify if any of the following apply to you.
Pregnant
Yes
No
Lactating
Yes
No
Menstruating
Yes
No
Pre-Menstrual
Yes
No
Trying to become Pregnant
Yes
No
Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc
Yes
No
Do you have active cold sores?
Yes
No
Have you received Botox or other injectable procedures within the past week?
Yes
No
Do you sunbathe or use tanning beds?
Yes
No
Do you experience redness, itching, or stinging on your skin?
Yes
No
Consent Form: Disclaimer
I understand a patch test is required before I have the above treatment due to a possible reaction to the product or glue. However, I am prepared to take full responsibility with this disclaimer and will not pursue any action against the therapist or salon should there be any reaction what so ever. No refunds will be given.
Please accept Disclaimer.
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