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Services

Showing all 9 results

24k Gold Facial
€140.00 Add to cart
BB Glow Treatment
€100.00 Add to cart
Chemical Peel
€80.00 Add to cart
Collagen Induction Therapy
€120.00 Add to cart
Dermaplaning
€60.00 Add to cart
Exosome Therapy
€300.00 Add to cart
Lip Blush Treatment
€100.00 Add to cart
Microneedling
€100.00 Add to cart
Scalp Regeneration
€150.00 Add to cart

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Client Information - Step 1 of 4

Name *

First

Last

Date of Birth *

Phone *

Email *

Address *

Address Line 1

City

State / Province / Region

Treatment *

Chemical Peel
Microneedling
Dermaplaning
24K Gold Facial

Please fill out only the selection relevant to the treatments you are interested in.

1: Do you have any known allergies? *

Yes
No

If yes (Please specify):

2: Are you currently taking any medications? *

Yes
No

If yes (Please list) :

3: Do you have any of the following medical conditions? *

Diabetes
High blood pressure
Heart condition
Blood disorders
Autoimmune disorders
Skin conditions (e.g., eczema, rosacea, psoriasis)
Cold sores or herpes simplex
Other
None of the above

Other (Please specify):

4: Are you pregnant or breastfeeding? *

Yes
No

5: Have you used Accutane or any other prescription acne medications within the last year? *

Yes
No

6: Do you smoke or use tobacco products? *

Yes
No

Chemical Peel:

1: What are your primary skin concerns? *

Fine lines/wrinkles
Acne/acne scars
Hyperpigmentation
Uneven skin tone
Dull skin
Rough texture
Sun damage
Other

Other (Please specify):

2: Are you currently using any skincare products containing retinol, glycolic acid, salicylic acid, or other exfoliants? *

Yes
No

3: Do you have a history of pigmentation issues (e.g., melasma, post-inflammatory hyperpigmentation)? *

Yes
No

4: Do you have any history of cold sores, especially around the mouth? *

Yes
No

Yes (Please list): *

5: Do you have a history of keloid scarring or poor wound healing? *

Yes
No

6: Have you had a chemical peel before? *

Yes
No

Yes (Please specify type and date):

Microneedling:

1: What are your primary skin concerns? (copy) *

Fine lines/wrinkles
Acne/acne scars
Hyperpigmentation
Uneven skin tone
Dull skin
Rough texture
Sun damage
Other

Other (Please specify): *

2: Have you had microneedling before? *

Yes
No

Yes (Please specify date): *

3: Do you have a history of keloid scarring or poor wound healing? *

Yes
No

4: Have you had any recent cosmetic procedures (e.g., Botox, fillers, laser treatments) within the last month? *

Yes
No

If yes (Please specify):

(Please Name to

Dermaplaning:

1: What are your primary skin concerns? (copy) (copy) *

Fine lines/wrinkles
Acne/acne scars
Hyperpigmentation
Uneven skin tone
Dull skin
Rough texture
Sun damage
Other

Other (Please specify): *

2. Have you had dermaplaning before? *

Yes
No

Yes (Please specify date): *

3: Do you have active acne, cold sores, or other skin infections? *

Yes
No

4: Are you currently on any blood thinners or anticoagulants? *

Yes
No

24K Gold Facial Section:

1: What are your primary skin concerns? *

Fine lines/wrinkles
Uneven skin tone
Dull skin
Loss of firmness
Other

Other (Please specify): *

2: Have you had a 24K Gold Facial before? *

Yes
No

Yes (Please specify date): *

3: Do you have any known sensitivities or allergies to gold-based products or other skincare ingredients? *

Yes
No

Yes (Please specify): *

Have you been informed about pre-treatment guidelines for each treatment? *

Yes
No

If yes, please acknowledge the following instructions:

For Chemical Peel: Avoid excessive sun exposure, discontinue retinoids and exfoliants for at least one week prior.

For Microneedling: Refrain from tanning, sun exposure, and avoid retinoids or exfoliating products 3-5 days prior.

For Dermaplaning: Avoid waxing, threading, and harsh exfoliants on the treatment area for at least 1-2 weeks prior.

Acknowledgment & Consent:

I, _________, confirm that I have provided accurate information in this form to the best of my knowledge. I understand the potential risks of chemical peel, microneedling, and dermaplaning treatments and agree to follow all pre- and post-care instructions provided by my aesthetic practitioner. *

Date *

This combined template should cover the necessary information and risks for each treatment, ensuring clients are well-prepared and informed.

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