Please download and read the following form regarding pre-treatment for facial injections prior to your session. PRE-TREATMENT INFORMATION for Facial InjectionsDownload Please complete the following form online prior to your dermal therapy visit. Alternatively, please arrive 15 minutes prior to your Dermal Treatment session to complete this form at Aliki Skin + Care. Dermal Therapy Treatment Consent Form This form is to be completed by all Aliki Skin + Care clients prior to any Dermal Therapy and rejuvenation treatments, Brow Artistry & Lash Treatments. Please complete the following online form as truly as possible. (Note: you can select more than one option in the lists). Name * First * Last Date of Birth * Email * Mobile Phone * Alternate/ Landline Phone * Address * Please Answer the following questions: When was your last DENTAL Hygiene visit? ( If it has been over 6 months, we would love to see you at iDental surgery). * Have you ever had any of the following treatments? * None of the below Anti-Wrinkle Injections Dermal Injections Cosmetic Surgery IPL / Laser to the face and/or neck Face Peel LED Light Therapy Carboxy Therapy Fat Reduction Facial Thread Lift CGF Growth Factor Facial Rejuvenation Body Henna Tooth Whitening Brow Tinting Lash Tint Lash Lift If you answered YES, please provide further details about DATE of last treatment or any details you would like to share (if applicable) My skin concerns are: * No Concerns ACNE BLACKHEADS/ WHITEHEADS DRY Skin OILY Skin COMBINATION Oily & Dry Skin CONGESTED Skin WRINKLES PIGMENTATION Sun Damaged Skin SENSITIVE Skin Aged Skin Eyes Lips Other Please provide further details of your eye/lip/face/neck/décolletage skin concerns if you have any What products are you currently using on your skin? * Have you ever used any Alpha Hydroxy Acid (AHA), glycolic products or any other peels? * YES, over 72 hours ago YES, in the past 72 Hours NO If YES, please provide further details such as product name and how often or when last used. How did your skin react? (if applicable) Have you ever had a professional skin peel or resurfacing? * YES NO If YES, please provide further details such as how long ago and what agent was used Have you had a dermal filler and/or anti-wrinkle injections in the last 4 weeks? * YES NO If YES, please provide further details such as dates and product name. Have you ever had irritant/allergic reaction to skin products? * YES NO Please provide further details such as product name and what happened (if applicable). Do you sunbathe or use fake tan or solariums? * YES, I sunbathe YES, I use fake tan YES, I go to solariums NO, I do not If so, when was the last time? Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon? * YES, and I apply sunscreen at least daily YES, but I do not apply sunscreeen NO Do you wear contact lenses? (please remove prior to your visit) * YES NO Medical Questionnaire (Please select those applicable to you) Are you presently under the care of a doctor? * YES NO If YES, please provide Doctor’s name and contact number Any known Allergies? * No Known Allergies Latex Allergy Lactose true allergy leading to e.g. anaphylaxis (not lactose intolerance) Formaldehyde Allergy Cyanoacrylate Allergy Hair Dye Henna Vitamin C Wax Tapes Other- please specify below Other Allergies or further details (if applicable) Medical Conditions (Please select the checkboxes that apply to you) * No known medical conditions Pregnant Breastfeeding Acne Autoimmune Disorder Bleed/Bruise easily (genetic) Bleed/Bruise easily (anticoagulant medication related) e.g. warfarin, clopidogrel, Pradaxa, Elequis, Xarelto) Bruise Easily (NSAID related) e.g. aspirin, ibuprofen, naproxen, celecoxib Cheloid / Hypertrophic scarring Diabetes Suffer from Coldsores Chemotherapy/ Raditation Skin Cancer of the face/ body Hepatitis HIV Please provide any additional information about your medical conditions that you think may be important: Have you had any surgery of any type in last twelve months? * YES NO If YES, please give dates and details Are you using Retin-A, Renova, Roaccutane, Accutane (an oral form of Retin-A) or prescription Vitamin A medicines or topical prescription creams/ lotions? YES NO If you answered YES, please provide further details e.g. How long were you on the medication? When did you last take/ apply this medication? Are you taking oral or using any topical antibiotics or other prescription or non-prescription medications for skin conditons? (e.g. doxycycline, spectinomycin, gentamycin) * NO YES, doxycycline YES, spectinomycin YES, gentamycin YES If you answered YES, please provide further details. Have you had Cortisone, Steroid, or Hormone tablets, patches or injections? * YES NO If you answered YES, please provide which one and when. Do you take or use any over the counter vitamins, medications or topical products on your skin? eg Vitamin E, Fish Oil * YES NO If you answered YES, please provide further details Do you take or use any other prescription medications prescribed by a doctor? * YES NO If you answered YES, please provide further details such as medication names/doses. Getting to know you a bit more Do you smoke? * YES NO If YES, how many cigarettes do you smoke per day? How much water consumed daily? * Almost none 1/2 Litre 1 Litre More than 1 Litre How many cups of coffee/tea consumed daily? * None 1-3 cups 3-5 cups constantly drinking it How many glasses of alcohol per week? * None 1-2 glasses 3-4 glasses 5-6 glasses 7-10 glasses More than 10 glasses Are you on a restricted diet? * YES NO If you answered YES, please provide further details. Please indicate your stress levels * Low Medium High Do you exercise regularly? * YES NO Please explain what and how often Are you interested in any of the following dermal therapy procedures? (Please select the checkboxes that apply to you) * Anti-Wrinkle Injections Hyaluronic Acid Rejuvenating Injections Mesotherapy & Microneedling Concentrated Growth Factor (CGF) Rejuvenation HydraFacial Lymphatic Drainage of Face & Neck Chemical Peels LED Light Therapy Laser Rejuvenation The Non-Surgical Facelift Carboxy Therapy Fat Reduction Aliki Natural Skin Care Products Brow Artistry Lash Lift & Tint Dental Visit- Hygiene Dental Visit- Smile Enhancement Dental Visit- Invisalign® Dental Visit- Dental Pain Dental Visit- Tooth Whitening Would you like to join the Aliki Skin + Care A-List? * YES, please sign me up to exclusive Aliki Skin + Care Events, Offers and Promotions NO, not at this stage The information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition. I understand that treatment is temporary in nature and will require re-treatment. * YES, I agree I have read the above information and if I have any concerns, I will address these with my treating dermal clinician. * YES, I agree Every treatment has a risk of reaction, even if you have had the same treatment at Aliki Skin + Care® or elsewhere many times before. Sometimes your skin can change, the products can be blended differently and sometimes medications can cause unwanted reactions. * YES, I understand I give permission to Dr Vicky Prokopiou and her team to perform dermal therapy procedures that we have discussed and will hold her and her staff harmless from any liability * YES, I agree I am aware that treatment is not an exact science and that no guarantees can or have been made with respect to the expected results and that further treatment and costs may be required to achieve the desired outcome. * YES, I agree A patch test is recommended for treatments such as tinting and henna. If you are concerned about getting a reaction please request a patch test. Costs are involved. Be aware that you will then need to wait 48 hours before you can have your treatment. * YES, I understand Treatment with Hyaluronic Acid is a medical procedure that carries with it certain potential complications and side effects, both local and systemic. I understand that when small amounts Dermal Filler are injected the skin they may limit my ability to perform facial expression or function. * YES, I agree I now fully understand and accept the benefits, risks, complications and side effects, both immediate and long-term, general and specific, which this procedure may cause. These include, but are not limited to: pain, swelling, redness, burning/stinging, tenderness, bleeding and bruising at the site of injection, post-operative headache, nausea, flu-like symptoms, local muscle weakness, paraesthesia, skin necrosis, scarring, blockage of blood vessels affecting skin health and rarely serious allergic reaction -anaphylaxis. * YES, I agree I understand that I need to fully pay for dermal therapies and services prior to or immediately after my treatment session is complete on the day. * YES, I agree If I do not confirm my session at least 24 hours prior to my session time, I understand that my session may be automatically cancelled. * YES, I agree I understand that failure to cancel within 24 hours or failure to attend a confirmed session will incur a fee. * YES, I agree PHOTOGRAPHY / VIDEO RELEASE I voluntarily consent to the taking, copyright, publication and use of my image in still photograph and/or video footage by Aliki Skin + Care. I am aware that my face may be identifiable and I agree only to the following uses of photographs or video footage: Please select the categories below to indicate your level of consent) * For educational publications, lectures, informational purposes, research. For general advertising, publicity and promotional purposes. I do not consent to the use of my photographs for anything other than my records reCAPTCHA If you are human, leave this field blank. Submit
