Client's Name

Email Address

Date of Birth

Address

Postcode

Contact Number

Skin products used at home:

Skin Care Goals:

Have you had a skin treatment done before? Yes No

Have you ever taken a reaction after a skin treatment service? Yes No

Do you have any allergy?

Are you using or taking any of the following? If YES, please click the button below:
Accutane
Retinoids such as Retin-A, Renova or Differin
Alpha-Hydroxy Acid / Beta-Hydroxy Acid / Glycolic Acid
Tetracycline

Any other medication:

Are you currently pregnant? Yes No

Have you had microdermabrasion/chemical peel/dermaplaning/laser treatments/botox/filler/ permanant makeup in the last 2 weeks? Yes No

Have you had a chemical peel in the last 7 days? Yes No

Have you had a cold sore in the last 10 days? Yes No

Have you been on a tanning bed/sun in the last 2 weeks? Yes No

I give Radiant Glow Aesthetics permission to take photos or videos during my session. These will be kept private unless I give permission for them to be used in their portfolio Yes No