Aura Skin and Headspa
Skin • Scalp • Wellbeing
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Clinic Details
Please confirm the clinic and treatment information
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Clinic Name:
Aura Skin and Headspa
Practitioner Name
Consultation Date
Treatment(s)
Facial
Microneedling
Chemical Peel
Head Spa
Other
Other:
Client Information
Your personal and contact details
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Full Name
Date of Birth
Age(18+ only)
Address
Contact Number
Email Address
Medical History
Please select any conditions that apply to you
==============================================
Please tick where applicable
Heart condition
High / low blood pressure
Diabetes
Autoimmune condition
Cancer (past or present)
Epilepsy
Blood disorders / clotting issues
Taking anticoagulants (blood thinners)
Compromised immune system
Additional Details
Skin & Scalp Health
Please select any current conditions
==============================================
Select any current conditions
Acne
Rosacea
Eczema
Psoriasis
Dermatitis
Hyperpigmentation
Keloid scarring
Cold sores (herpes simplex)
Open wounds / broken skin
Active infection (skin or scalp)
Additional Details
Medication & Products
Please indicate any medications or skincare products you are currently using
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Select medication & products
Prescription medication
Roaccutane / Isotretinoin (last 12 months)
Retinoids / Vitamin A
Acids / exfoliants
Steroids
Antibiotics
Medication / Product List
Lifestyle & Other Factors
Please select any that apply to you
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Select lifestyle & other factors
Pregnant or breastfeeding
Recent sunburn or tanning (last 14 days)
Recent laser, peel or microneedling
Botox / fillers (last 4 weeks)
Hair extensions
Smoking or vaping
Allergies
Please indicate any known allergies
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Select allergies
Skincare products
Medication
Latex
Metals
Other
Please specify:
Practitioner Skin Assessment
To be completed by the practitioner
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Skin type
Dry
Oily
Combination
Sensitive
Fitzpatrick type
I
II
III
IV
V
VI
Observations:
Contraindications Present?
Yes
No
Treatment
Treatment adapted
Treatment declined if necessary
Treatment Risks Explained
Please confirm you understand the following potential risks
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Select treatment risks explained
Temporary redness or sensitivity
Possible peeling or flaking
Mild swelling or irritation
Risk of pigmentation if aftercare not followed
Infection risk if advice ignored
Results vary and are not guaranteed
Aftercare Agreement
Important information about post-treatment care
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I understand the importance of:
• Following aftercare instructions
• Sun avoidance and SPF use where advised
•Contacting Aura Skin and Headspa if concerns arise
I confirm I understand the aftercare advice
Client Consent
Please review and confirm each statement
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I confirm that:
• I have provided accurate and honest information
• A face-to-face consultation has taken place
• The treatment, risks, benefits and alternatives were explained
• I am over 18 years of age
• I consent to the treatment listed above
Client Signature
Client Signature Date
Practitioner Signature
Practitioner Signature Date
Professional Use Only
To be completed by the practitioner
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Professional Use Only
Insurance valid
Infection control followed
Records stored securely (GDPR compliant)
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