Client Consultation Form

Full Name *

First Name

Last Name

Would you like to receive educational blogs and promotions via email? *

Yes

No

Are you happy for us to share your before and afters on social media? *

Yes

No

1. Have you had any facial surgery/botox/fillers in the last 3 months? *

Yes

No

2. Have you any of the following health conditions, past or present?

Cancer

Diabetes

Epilepsy

HIV/AIDS

Heart Problems

Thyroid Condition

Hepatitis

Herpes/Cold Sores

Claustrophobia

Asthma

Hormonal Imbalance

Auto-immune disorder

Haemophilia

Depression

5. Do you smoke? *

Yes

No

6. Are you on a specific diet? *

Yes

No

7. Do you have metal implants?

Yes

No

8. Do you have any specific skin conditions? *

Yes

No

9. Are you regularly exposed to UV for long periods of time? *

Yes

No

10. Have you ever used a solarium bed? Y

Yes

No

11. Have you had high amounts of sun exposure in the last 2 weeks? *

Yes

No

12. Do you experience oily “shine” during the day? *

Yes

No

13. Do you believe your skin to be sensitive? *

Yes

No

14. Do you experience irregular or painful periods? *

Yes

No

15. Do you suffer from Endometriosis or PCOS? *

Yes

No

16. Do you have any allergies or food intolerances? *

Yes

No

17. Are you currently pregnant or breast feeding? *

Yes

No

22. Do you suffer from Eczema, Psoriasis or Dermatitis? *

Yes

No

23. Do you suffer from digestive issues, constipation or diarrhoea? *

Yes

No

24. Are you currently working with a Naturopath or Chinese Dr? *

Yes

No

25. Are you exposed to high amounts of stress? *

Yes

No

Disclaimer *

I give my consent to receive treatments from SJM Skin Aesthetics. I understand that prior to every treatment, I will advise my therapist of any new medications, skin conditions or any other bodily changes, eg. Pregnancy, other skin treatments or new products. I acknowledge that I will not use prescriptive creams + topical antibiotics prior to the treatment, and not have botox or fillers for two weeks before and two weeks after treatment. I understand that I should follow the therapist’s aftercare advice. This may include recommended skincare products, advising SJM Skin Aesthetics of any concerns or changes immediately after the treatment, seek the advice of my Dr if I experience any ill effects and use sun protection at least SPF 15+ on exposed areas being treated. For 24 hours after my treatment I also agree that I will not: undertake excessive or vigorous physical activity, avoid direct sun exposure, and use approved topical skincare as recommended by my therapist. I hereby declare that I have read and fully understand the above information. I have been informed about specific treatments and its possible side effects and all of my questions have been addressed in a satisfactory manner. No guarantees have been made in regard to final results or lessened potential risks. I agree to proceed with treatment knowing all of the associated risks and confirm and agree that any treatment is at my own risk. *Cancellation Policy* We request a $100 deposit as security to make your booking. In case of a no show or late cancellation, this deposit is redeemed as a cancellation fee (this is anytime after 48 hours of receiving your reminder text). If this occurs, a $100 cancellation fee will be charged or $150 for appointments over 1.5 hours. I agree to this Cancellation Policy and understand I will be charged for late (within 48 hours) cancellation or rescheduling of my appointment. This policy applies to all cancellation reasons: illness, sudden accidents, COVID-19 illness/close contact, work commitments etc.

I Agree