Home
About Us
Forms
Lily Brow Bar Consultation Form
Permanent Makeup Client Consultation Form
PDO Threads Procedure Consent Form
Information and Consent For Aqualyx
Skin Booster Consultation And Consent Form
Laser / IPL Consultation Form
IV Therapy Informed Consent Form
Aesthetic Consultation
Waxing Consent Form
Anti-Wrinkle Injection and Cosmetic Procedure
Eyelash Extention Client Record Card
Massage / Holistic / Facial Consultation
Hyaluronidase Form
Micro Needling History & Consent Form
Plasma Treatment Form
Vitamin Injection Consultation
Book Appointment
Contact Us
Our Catalogue
Our Catalogue
Aesthetic Consultation
Home
Aesthetic Consultation
Aesthetic Consultation
Date
Client Name
Treatment Being Received
Have you received this treatment before. Yes / No If yes did the treatment meet your needs and expectations?
What are your main reasons for have the treatment with us today?
Enhance Lips
Select
Yes
No
Soften Nasal Folds
Select
Yes
No
Soften Marionette Lines
Select
Yes
No
Soften Wrinkles
Select
Yes
No
Reduce Fine Lines
Select
Yes
No
Enhance Cheeks
Select
Yes
No
Enhance Jaw Line
Select
Yes
No
Rebalance Nose
Select
Yes
No
Rebalance Chin
Select
Yes
No
Improve Skin Texture
Select
Yes
No
Reduce Dark Eye Area
Select
Yes
No
Reduce Pigmentation
Select
Yes
No
Improve Skin colour
Select
Yes
No
Lift Contours
Select
Yes
No
Reduce Lose Skin
Select
Yes
No
Improve Skin Condition
Select
Yes
No
Improve Neck Area
Select
Yes
No
Fat Reduction
Select
Yes
No
Cellulite Reduction
Select
Yes
No
Improve Body Firmness
Select
Yes
No
Other
What is your main facial/body concerns?
Cellulite
Select
Yes
No
Lose Skin
Select
Yes
No
Dry Skin
Select
Yes
No
Oily Skin
Select
Yes
No
Body Weight
Select
Yes
No
Poor Texture
Select
Yes
No
Skin Aging
Select
Yes
No
Fine Lines
Select
Yes
No
Wrinkles
Select
Yes
No
Pigmentation
Select
Yes
No
Scaring
Select
Yes
No
Dropped Contours
Select
Yes
No
Fat Pockets
Select
Yes
No
Skin Colour
Select
Yes
No
Skin Imperfection
Select
Yes
No
Veins
Select
Yes
No
Blocked Pores
Select
Yes
No
Dehydration
Select
Yes
No
Poor Radiance
Select
Yes
No
Water Retention
Select
Yes
No
Other
What treatment are you currently doing to improve your main concern?
Describe your tolerance to needles?
Select
Low
Medium
High
If you have circled a low tolerance, please explain more about any fear you may have?
Do you have a known allergy to topical anaesthetic/lidocaine?
Select
Yes
No
Please answer Yes or No to the following statements and sign below-
I give my permission for the practitioner to administer topical anaesthetic/ lidocaine to the area being treated on my body
Select
Yes
No
Aesthetic treatments are classed as invasive. I understand I may experience one or more of the following normal sensations during treatment-Discomfort/ Tingling/ Watery Eyes/ Sharp Pain/ Numbness/ Heat
Select
Yes
No
Aesthetic treatments are classed as invasive. Due to this I understand I may experience one or more of the following normal contra-actions after treatment- Bruising/ Swelling/ Discomfort
Select
Yes
No
I understand that bruising can last up to 2 weeks post treatment
Select
Yes
No
I understand there are no guarantees as to the success or longevity of my treatment
Select
Yes
No
I understand that results are only temporary, and my practitioner has explained the expected time frame
Select
Yes
No
I understand my condition or medication may affect the treatment including bruising, bleeding and additional healing time
Select
Yes
No
I understand that my practitioner is required to take photographs of the treatment areas before and after every procedure and agree to this being done
Select
Yes
No
My technician has discussed likely outcomes with me and recommended a treatment plan
Select
Yes
No
I have been given aftercare Instructions and understand that I must stick to these instructions
Select
Yes
No
Do you have any concerns or additional questions?
Client Name
Client Signature
Clear Signature
Date
Facial / Body Analysis & Mapping
© 2024 Copyrights By
Lily's Beauty & Aesthetic
and Proudly Powered By
Sabhaya Solutions.
.png)
.svg){kind=icon}
