Client Consultation Form – Microdermabrasion Treatments
College Name:
College Number:
Student Name:
Student Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
30–40
40–50
50–60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical
permission cannot be obtained clients must give their informed consent in writing prior to treatment.
(select if/where appropriate):
Pregnancy
Diabetes
Cardiovascular conditions (thrombosis, phlebitis,
Asthma
hypertension, hypotension, heart conditions)
Bells Palsy
Haemophilia
Trapped/Pinched nerve
Any condition already being treated by a GP or
Inflamed nerve
Dermatologist
Cancer
Medical oedema
Spastic conditions
Osteoporosis
Undiagnosed pain
Nervous/Psychotic conditions
When taking prescribed medication
Epilepsy
Recent cosmetic or other surgery
Recent operations
Injections for personal enhancement
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate)
Fever
Inflammation
Contagious or infectious diseases
Cuts
Under the influence of recreational drugs or
Bruises
alcohol
Abrasions
Diarrhoea and vomiting
Scar tissues (2 years for major operation and 6
Any known allergies
months for a small scar)
Skin cancer
Sunburn
Hepatitis
Haematoma
Skin diseases
Recent fractures (minimum 3 months)
Undiagnosed lumps and bumps
Any metal pins or plates
Hypersensitive skin
Loss of skin sensation (tactile test)
Broken capillaries
Botox/dermal fillers (1 week following
Localised swelling
treatment)
SKIN TEST (select if/where appropriate):
Moisture content:
Excellent
Good
Fair
Poor
Muscle tone:
Excellent
Good
Fair
Poor
Elasticity:
Excellent
Good
Fair
Poor
Sensitivity:
High
Medium
Low
Skins healing ability: Excellent
Good
Fair
Poor
Skin tone:
Fair
Medium
Dark
Olive
Circulation:
Good
Normal
Poor
Pores:
Fine
Dilated
Comodones
Milia
V2.0
OVERALL SKIN TYPE/CHARACTERISTICS (select if/where appropriate):
White
Black
Asian skin type
Mixed
Dry
Oily
Combination
Brief Description:
REASON/S FOR TREATMENT (select if/where appropriate):
Removal of: Comodones
Milia
Treatment of: Fine lines
Wrinkles
Scars
Lip lines
Mature
Frown lines
Treatment details:
Client feedback:
After/Home care advice given:
Student’s/Therapist Signature……………………………
Client’s Signature…………………………………………..
MICRODERMABRASION TREATMENT FOLLOW UP SHEET
Treatment details:
Client feedback:
2
Young
After/Home care advice given:
Date of treatment……………………
Student’s/Therapist Signature……………………………
Client’s Signature…………………………………………..
3