CLINICAL TREATMENT CONSULTATION FORM
Practitioner: Dr Reena Halai
PATIENT DETAILS:
Full name *
Date of birth *
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Address *
Telephone *
Email *
Emergency Contact:
Name: *
Relationship *
Telephone *
Lifestyle:
Occupation: *
Do you smoke? *
Daily water intake: *
Recent sun / UV exposure / holidays planned: *
Main concerns / reason for visit: *
What skincare products are you currently using? Please tell me your skin care routine AM *
What skincare products are you currently using? Please tell me your skin care routine PM *
Areas of concern:
Please indicate areas of concern: *
Required
Do you have any important personal engagements booked *
HEALTH
Are you currently pregnant or breastfeeding? *
Are you currently taking the or have taken any of the following medications?
If ‘Yes’ please give more details or list any other medication not listed above:
Do you have any known allergies? (e.g. latex, metals, shellfish, nuts, penicillin) *
If ‘Yes’ please give details
Have you suffered from any of the following?
Have you ever been admitted to hospital? *
If ‘Yes’ please give details:
Have you ever experienced any adverse reaction to any form of anaesthetic? *
If ‘Yes’ please give details:
Have you ever had any previous surgery (non-cosmetic)? *
If ‘Yes’ please give details:
Have you had any of the following procedures in the last 3 months on the area to be treated with microneedling?
Are you currently experiencing any of the following active skin conditions?
Have you used any products containing any of the following ingredients in the area(s) to be treated?
Please write any additional comments/information that you think may be useful
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