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About Us
Services
Contact

Client Consultation Form

Client Consultation

Form

Please enable JavaScript in your browser to complete this form.

Date *

Name *

First

Last

Work No *

Phone No *

Email *

Do you have any Allergies *

Yes
No

Please notify if you have any Health Concerns

Are you pregnant or could be pregnant *

Yes
No

Please notify if you have any Health Concerns

Are you Breast feeding *

Yes
No

Please notify if you have any Health Concerns

Mitral Valve *

Yes
No

Please notify if you have any Health Concerns

Hepatitis/HIV *

Yes
No

Please notify if you have any Health Concerns

Bruise/Bleed easily *

Yes
No

Please notify if you have any Health Concerns

Do you suffer from Epilepsy or history of seizures *

Yes
No

Please notify if you have any Health Concerns

Diabeties *

Yes
No

Please notify if you have any Health Concerns

Have you had any problems / reactions to Dental Anaesthetic/Dental Blocks or topical Numbing Creams, If yes, please specify *

Yes
No

Please notify if you have any Health Concerns

Heart Conditions/Concerns of any kind, Pacemaker or implanted devices *

Yes
No

Please notify if you have any Health Concerns

Metal Implants *

Yes
No

Please notify if you have any Health Concerns

Anxiety/Depression and if so please state any medication you maybe taking *

Yes
No

Please notify if you have any Health Concerns

Allergy to latex *

Yes
No

Please notify if you have any Health Concerns

Radiation or Chemotherapy – If yes how long ago did treatment finish *

Yes
No

Please notify if you have any Health Concerns

Currently using Retin-A, Alpha Hydroxy or Glycolic skin care products *

Yes
No

Please notify if you have any Health Concerns

Have previously or at present taken acne medication ie; Roaccutane *

Yes
No

Please notify if you have any Health Concerns

Facial surgery last 3 months *

Yes
No

Please notify if you have any Health Concerns

Eye infections *

Yes
No

Please notify if you have any Health Concerns

Scar heavily/Keloid *

Yes
No

Please notify if you have any Health Concerns

Contact Lenses *

Yes
No

Please notify if you have any Health Concerns

Botox, Fillers – If so, have you had any in the last 2 weeks? *

Yes
No

Please notify if you have any Health Concerns

Blepharitis *

Yes
No

Please notify if you have any Health Concerns

Thyroid problems *

Yes
No

Please notify if you have any Health Concerns

Autoimmune disease *

Yes
No

Please notify if you have any Health Concerns

Cold Sores *

Yes
No

Please notify if you have any Health Concerns

Other please specify *

Yes
No

Please notify if you have any Health Concerns

If yes

Are you under any special care or medical supervision under a doctor’s supervision? *

Yes
No

Please notify if you have any Health Concerns

Have you recently undergone or planning to have surgery? *

Yes
No

Please notify if you have any Health Concerns

Please list any current medications you are taking, including any health supplements:

I consent to my images being cropped and used for advertising *

Yes
No

Checkboxes *

I understand that more than 1 treatment may be necessary to achieve the desired results as discussed with the technician, and understand the final outcome cannot be guaranteed. I accept and understand there are no refunds for this procedure.
I understand that all procedures carry a risk of infection and agree to contact the technician immediately should there be any concerns.
I accept all responsibility for the aftercare of my treatment and agree adhere to the guidelines I have been given.
I consent to before and after photos to be kept with my file.
This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I also am aware that failure to disclose information pertinent to my treatment could have a direct bearing on treatment outcome. I am not under the influence of Alcohol or illegal drugs, or pregnant.

Please sign if you agree to all the above

Name *

Signature or Initials *

(The full name or initials will symbolize the signature of consent for this consultation form).

Checkboxes (copy) *

I hereby release the technician and/ or any of the practioner’s or technicians associates from any and all claims, which I may have now, or in the future arising from the treatment.
I understand that the application of this is artistic in nature and that no result can be guaranteed or certain.
The Microneedling process has been explained to me and I have been fully informed of the procedure(s) performed.
I will not hold the practioner/technician responsible in the event of any damage and shall not be entitled to take action against her/him at law and equity for such treatment.
I execute this release having read and fully understand it, and do so completely voluntarily.

Signature or Initials *

(The full name or initials will symbolize the signature of consent for this consultation form).

Numbers

Brisbane QLD, Australia

Salon Lane, West Village, Level 1, Factory 2

97 Boundary Street

West End

4101

Working Hours

Monday to Saturday: By Appointment Only

De Luetz Beauty

Phone

+61 431 811 067

Email

deluetzinfo@gmail.com

DE LUETZ BEAUTY