Beauty Parlour - Online Therapist

dermalogica products and treatments at the Beauty Parlour Edinburgh

Tel. 0131 476 4300

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Terms & Conditions

Online Therapist - Consultation Card

To allow The Beauty Parlour to evaluate your special needs in order to ensure the correct product selection, please fill out the consultation card below. The information sent will be treated with complete confidentiality. For more information, please see our terms and conditions.

CONTACT DETAILS

Name*
Address
Phone
Email
Age	Under 21 21 - 30 31 - 40 41 - 50 51 - 60 Over 60

YOUR HEALTH

Within the last year, have you been under a physician's care?	Yes No
Within the last year, have you been under a dermatologist's care?	Yes No
Within the last nine months, have you undergone any surgery?	Yes Specify: No
Have you had any of these health problems in the past or present?	Cancer Diabetes Epilepsy Heart problem Hormone imbalance Spinal injury Hysterectomy Thyroid condition Varicose veins Systemic disease
List medications, supplements, vitamins, diuretics, slimming tablets etc that you take regularly:
Do you smoke?	Yes No
Do you follow a restricted diet?	Yes No
Do you have regular sleep patterns?	Yes No
Do you wear contact lenses?	Yes No
Do you have metal implants or a pacemaker?	Yes No

YOUR SKIN

With what temperature of water do you cleanse?	Cool Warm Hot
Do you have any special skin problems pertaining to your face or body?	Yes Specify: No
What skin care products are you currently using?	Soap Cleanser Toner Moisturiser Masque Exfoliator Eye products Others

EXFOLIATION HISTORY

Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?	Yes No
In the last month?	Yes No
Do you use Accutane, Retin A, Renova or Adapalene?	Yes No
In the last 3 months?	Yes No
Do you use an acne medication?	Yes No
In the last 6 months?	Yes Specify: No
Are you currently using any products that contain the following ingredients?	Glycolic acid Lactic acid Any exfoliating scrubs Any hydroxy acid product Vitamin A derivatives (i.e. retinol)

MOISTURE HYDRATION

How much plain water do you consume daily?
How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?	Flakiness Tightness Obvious Dryness
What spf sunscreen do you use on your face?
What spf sunscreen do you use on your body?
Do you sunbathe and/or use tanning beds?	Yes No

CAPILLARY ACTIVITY

Do you burn easily in moderate sunlight?	Yes No
Do you blush easily when nervous?	Yes No
Do you have a tendency to redness?	Yes No
Do you suffer from sinus problems?	Yes No

OIL SECRETION

Do you ever experience oily shine during the day?	Yes No Occasionally
Do you ever experience skin breakouts?	Yes No Occasionally

NERVE ACTIVITY

Do you drink caffeinated beverages?	Yes Daily: No
Do you ever experience a burning, itching sensation on your skin?	Yes No
What is your pain threshold?	Low Medium High
Have you ever had a reaction to any of the following?	Cosmetics Medicine Iodine Pollen Food Hydroxy acids Animals Fragrance Sunscreens

FEMALE CLIENTS ONLY

Are you taking oral contraception?	Yes No
Are you pregnant or trying to become pregnant?	Yes No
Are you lactating?	Yes No

MALE CLIENTS ONLY

What is your current shaving system?	Electric Wet
Do you experience irritation from shaving?	Yes No
Do you experience ingrown hairs?	Yes No

CONFIRMATION AND SIGNATURE

To the best of my knowledge, I confirm that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.*
Client's Name*

Required fields are marked *

Important: Your privacy is our concern. All information sent through this page is not stored, sold or rented and used only to contact you to answer your question.

Problems? Please contact us for help.

dermalogica

We use dermalogica® products in all our treatments. Read more >.

Epil-Pro

We use Epil-Pro®, the revolutionary hair-removal system. Read more >.

BABTAC

Member of the British Association of Beauty Therapy and Cosmetology