LED FACE MASK CONSULTATION FORM

Name Date of Consultation

Address:

Tel No: Mobile:

Date of Birth Occupation

Email:
Doctors Name &
Address

Do any of the following apply to you:

Epileptic Pregnant Cancer
Thyroid problems Lupus Anxiety
Depression Diabetes Heart problems
High blood pressure Acne Cancer
Recent facial surgery (in last Bacterial infection Fungal infection
3 months)
Taking or recently taken Eczema/Psoriasis/
Roaccutane (in last 12 Dermatitis
months)
IF TICKED YES TO ANY OF THE ABOVE, WRITE IN FURTHER INFORMATION BELOW

Are you taking any of the following drugs:

Anti-anxiety drugs (e.g. Antibacterial drugs (e.g. Antibiotics (quinolones,
alprazolam, chlorhexidine, sulphonamides,
chloridiazepoxide) hexachlorophene) tetracyclines,
trimeothoprim)
Antidepressants (e.g. Anti-fungals (e.g. Anti-hyperglycaemic
tricyclics) griseofulvin) drugs (sulfonylureas)
Anti-malarials (e.g. Anti-psychotics (e.g. Diuretics (e.g. frusemide,
chloroquine, quinine) phenothiazines) thiazides)
Heart drugs (e.g. Acne drugs (isotretinoin) Lithium
amiodarone, quinidine)
Melatonin Methotrexate Steroids/cortisone
Phenothiazine
What other prescription medication are you taking?
 Do you have any other relevant conditions not mentioned above?

Why have you come for an LED Facial Treatment?

ESTABLISH AREAS OF CONCERN:

Client declaration: I confirm that to the best of my knowledge the answers that I have given are correct and I
have not withheld any information that may be relevant to my treatment. I have been informed about the
expected results and effects of the treatment and agree to follow all aftercare advice provided to me by my
therapist.

Signed: ………………………………………………………………………………. Date: ……………………………………………………..

Therapist: …………………………………………………………………………… Date: …………………………………………………..