Treatment Consultation Form || Lilys Beauty & Aesthetic

A consultation is required for all Million Dollar Facial Treatments to ensure the correct treatment is selected and performed by a million dollar platinum technician.

Millon Dollar Details

First Name

Surname

Address

Postcode

Date Of Birth

Tel. No.

Mobile No.

Email

Skin Type

Skin Concerns

Skin Characteristics

Skincare Routine

If You Select Other Then Please Specify

Body Concerns

Lifestyle

Smoking (Daily)

Alcohol (Weekly Units)

Water Intake (Daily)

Balanced Diet

Exercise

Medical Questionnaire

Are you currently undergoing medical supervision or treatment?

Do you have any allergies? E.g. ingredients, Asprin, albumin, metallic.

Do you suffer with any heart conditions, blood pressure or circulation problems?

Do you have cancer or undergoing radio or chemotherapy?

Do you have any lymphatic conditions? E.g Lymphodema, Lupus or any other Condition that can affect your immune system.

Do you have any skin irritations, sores or lesions on the area to be treated?

Are you taking any oral or topical medication to treat a skin condition e.g. steroids, acne medication, hydrocortisone.

Have you had any recent surgery or aesthetic treatments?

Have you received any facials, skin treatments or hair removal in the last 4 weeks?

Are you using any exfoliants? Including AHAS, BHAS, glycolic or lactic acids?

you have any other medical conditions?

Do you suffer from keloid or hypertrophic scars?

Are you pregnant or breastfeeding?

Additional Comments

understand that there are certain Contraindications that would prevent me from receving a treatment and there will be an alternative recommendation if suitable.

Million Dollar Chosen Treatment

Advised Million Dollar Treatment Plan

Advided Medi Homecare Treatment Plan

The advanced treatments may cause instant reactions to the skin including skin redness and flushing, tightness, itching, sensitivity. and pinpoint bleeding. Effects will usually typically resolve within hours, but some people react differently and may take slightly longer.
The use of a sharp instrument creates a possibility of nicks and cuts whilst every precaution is taken I do understand the risks.
I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.
I understand that I may require a series of treatments normally with at least 2-4 weeks between procedures, to achieve the maximum desired results.
I have been given post treatment advice and understand to agree to follow all the guidance to minimise the risk of side effects.
I give full consent to use my before and after pictures to be taken and used for marketing purposes.

Additional Notes