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Facial & Skincare Form

Welcome to The Radiance Space

To provide you with personalised care and the best experience, please take a moment to complete this facial medical history form. The information you provide is confidential and helps us understand your needs to offer the most suitable treatments for your skin.

Full name*

Reason for the consultation*

What would you like to achieve from your treatment?

Work title*

Life style*

Active

Moderately active

Sedentary

Sun exposure*

Daily

Sometimes

Never

Do you regularly use sunscreen?*

Daily

Sometimes

Never

What is your skin type?*

Normal

Oily

Dry

Combo

Unsure

Do you have or have you had any of the following skin concerns? If yes, please select them:*

Acne

Blackheads

Contagious diseases

Dryness/Dull skin

Eczema

Fine lines/Wrinkles

Herpes

Hyper pigmentation

Hypo pigmentation

Keloid scarring

Milia

Lupus

Oily skin

Psoriasis

Redness

Rosacea

Scarring

Sensitivity

Sun damage

Phlebitis, blood clots

Skin disease/lesions

Thyroid condition

Have you ever had any facial treatment for the above concern?*

Yes

Please explain*

Have you ever used acne medication?*

Yes

If yes, when and which drug?*

Have you received Botox, Restylane, or Collagen injections in the last 3 months?*

Yes

If yes, please describe:*

How does your skin heal?*

Fast

Slow

Scars

Pigments

Normal

Please list all the products you currently use in your skincare routine:*

Find Us

Level 1 - Suite 1.07

685 Pittwater Rd, Dee Why 2099, NSW

Enquiries

Tel: 0452 583 776

Email: contact.sabrinagirotto@gmail.com

Working hours

Monday 9am - 7pm

Tuesday 9am - 7pm

Wednesday 9am - 7pm

Thursday 9am - 7pm

Friday 8am - 5pm

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