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Home
About
About
Brands
Treatments
Skin Treatments
Results
Before and Afters
Brides
Blog
Explore Blogs
Shop
Shop All Products
Treatments & Vouchers
Book
Contact
Contact
Consultation Form
Skin needling Consultation Form
IPL Consultation Form
Client Feedback
FAQ
Skin Needling Consultation Form
Full Name
*
First Name
Last Name
Address
Post Code
*
D.O.B
*
Phone
*
Email
*
How did you find out about SJM Skin Aesthetics?
Are you happy for us to share your before and afters on social media?
*
Yes
No
Are you recovering from any major medical treatments within the past 3 months? If YES, please specify
What products do you use on your skin?
Have you used any products containing any of the following ingredients?
*
Alpha/Beta Hydroxyl Acids (Lactic, Salicylic, Glycolic)
Retinoids (Vitamin A)
Benzoyl Peroxide
Hydroquinone/Kojic Acid/Azaelic Acid
No, none
Skin Needling is not suitable for patients experiencing the following. Please select if applicable to you.
*
Papular/Pustular Rosacea
Open Lesions
Acne Vulgaris Stages 3+
Herpes Simplex
Warts
Skin Cancer
Haemophilia
Bacterial/Fungal Infection
Auto-Immune Diseases
Eczema or Dermatitis in the area
Diabetes
Roaccutane treatment less than 6 months ago
Blood thinning medication/blood clotting disorders
Easily bruised
I give my consent to receive treatment. I understand that my skin may be red and feel like moderate sunburn. I consent that I do not suffer from any of the above contraindications and to contact my clinician with any issues relating. I understand a course of treatments will be required for optimal results along with quality skincare.
*
Yes, I agree
Thank you, your consultation form has been received.
SJM Skin Aesthetics