Hydro Facial Consultation Form

First Name *

Last Name

Date of Birth *

Gender *

Phone *

Email *

Address

City

State / County

Postal Code

2. Client Evaluation

This information helps the clinic evaluate your concerns and recommend suitable care.

How often do you exercise? *

How many hours do you sleep per night? *

Stress level (1–10) *

Occupation *

Age of children (if any)

3. Nutrition

Weekly Food Frequency

Sugar

Spicy Foods

Takeaways

Salty Food

Snack Foods

Fast Foods

Daily Fluid Intake

Water

Juices

Tea

Coffee

Alcohol

Fizzy Drinks

Specific dietary requirements?

4. Health / Medical

Health Conditions

Prescribed medications from your GP

Non-prescription medications

Medication / Treatment Information

Retin-A

Accutane / Tetracycline

Contraceptives / HRT

Diuretics

Antibiotics

Steroid Cream

5. Surgery & Previous Treatments

Any surgery or plastic surgery?

If yes, when?

Where on your body?

Procedure details

Have you undergone dermatologist treatment, skin peels, Botox, dermal filler, threads, IPL or laser?

If yes, when?

What type of treatment?

Procedure details

6. Home Skin Care Regime

7. Concerns & Expectations

What are your specific concerns?

Have you previously received hydro peel, radio frequency, electro-ion therapy or ultrasound?

What were the results?

What are your expectations of your chosen treatment?

8. Client Release & Contra-indications

9. Photo Consent

10. Signature

Client Full Name / Signature *

Date *

11. Other Services

Skin AnalysisFacial Treatments Skin uplift or lighteningBody Contouring Treatments Injectable Treatments

Submitted information is emailed to the clinic and is not stored in this website form database.

Hydro Facial Consultation & Consent

1. Client Details