Facial Treatment Consultation & Consent Form

Thank you for booking with Layan Holistic Wellness.

Please take a moment to complete this form so I can understand your skin, needs, and preferences, and make your treatment as safe, comfortable, and personalised as possible. All information is confidential and used only for your care.

1. Client Details

Full Name:

Age:

Phone Number:

Email Address:

2. Medical History

Are you currently pregnant or breastfeeding?

Are you currently pregnant or breastfeeding?

Do you have any known medical conditions?

Do you have any known medical conditions?

Do you have any skin conditions? (e.g. eczema, psoriasis, rosacea, dermatitis)

Do you have any skin conditions?

Do you have any allergies? (medications, skincare, food, latex)

Do you have any allergies?

Do you have a history of cold sores (herpes simplex)?

Do you have a history of cold sores?

3. Medications

Are you currently taking any medications?

Are you currently taking any medications?

Are you using any topical prescriptions? (e.g. retinoids, steroids, acne treatments)

Are you using any topical prescriptions?

Have you taken Isotretinoin (e.g. Accutane) in the past 6–12 months?

Have you taken Isotretinoin

4. Recent Skin Treatments (Last 2 Weeks)

Have you had any of the following recently?

Laser hair removal

Laser hair removal

Chemical peel

Chemical peel

Microneedling

Microneedling

Microdermabrasion

Microdermabrasion

Botox or dermal fillers

Botox or dermal fillers

Other facial treatments

Other facial treatments

If yes, please specify dates/details:

5. Skin Concerns & Goals

What are your main skin concerns?

Acne
Pigmentation
Fine lines / wrinkles
Dehydration
Sensitivity
Other:

6. Contraindications & Safety Check

Please indicate if you currently have or have a history of any of the following:

Active skin infection, open wounds, or cold sores

Active skin infection, open wounds, or cold sores

Severe or cystic acne

Severe or cystic acne

Sunburn or irritated skin

Sunburn or irritated skin

Recent facial surgery or procedures

Recent facial surgery or procedures

Cancer (current or past)

Cancer (current or past)

Currently undergoing cancer treatment

Currently undergoing cancer treatment

Recent chemotherapy or radiotherapy

Recent chemotherapy or radiotherapy

Autoimmune disease (e.g. lupus, rheumatoid arthritis) 

Autoimmune disease (e.g. lupus, rheumatoid arthritis) 

Diabetes

Diabetes

Use of blood-thinning medication

Use of blood-thinning medication

Skin sensitivity or history of adverse reactions to treatments

Skin sensitivity or history of adverse reactions to treatments

Any other medical condition or concern not listed:

7. Consent

I confirm that:

The information I have provided is accurate and complete

I understand the procedure, benefits, and possible side effects

I have had the opportunity to ask questions

I consent to receiving the HydraFacial treatment

Confirmed