Qualification of the client for the procedure Name First Name Last Name Date of Birth Occupation Email Phone (###) ### #### You don’t have to answer all of the questions if you don’t know or are unsure of the answer. IN YOUR OPINION: 1. What is the reason for undergoing the procedure? Wrinkles Pigmentation Acne Blackheads Capillaries Sagging skin Dry skin Swelling Other: 2. What is your biggest issue from the above mentioned? 3. What is your skin type? (According to you) 4. Have you had any tretments done before? YES NO If YES (which ones?) 5. Have there been any complications after undergoing any of the procedures? YES NO 6. Were you satisfied with the results after the procedure? YES NO If "NO" - Please provide details, specifying which procedure and why. 7. What are your expectations regarding the procedure? 8. Are you considering needle treatments? (Microneedling, needle mesotherapy, boosters, radiofrequency microneedling) YES NO 9. What is your daily skincare routine? Toner SPF Micellar water Facial cleanser Day cream Night cream Eye cream Serum Natural oils 10. Do you regularly exfoliate your skin? (e.g., with peeling) YES NO 11. Are you satisfied with the cosmetics you use? YES NO 12. Do you feel you need assistance in choosing skincare products? YES NO 13. Do you have any allergies? YES NO 14. Do you have any health problems? YES NO If YES (which ones?) 15. Are you taking any medications? YES NO If YES (which ones?) 16. Are you taking any supplements? YES NO If YES (which ones?) 17. Would you describe your lifestyle as healthy? YES I try to live a healthy lifestyle Not really I need motivation to live a healthy lifestyle NO Consultation form has been prepared to ensure the highest level of safety. It serves as the basis for excluding certain treatments in accordance with contraindications. All information is confidential and may only be disclosed to YA Studio. I consent to the processing of personal data for the purpose of sending commercial information to my phone number provided above in the contact form. Giving consent is voluntary. I acknowledge that I may withdraw this consent at any time by sending a message to the provided phone number. Withdrawal of my consent does not affect the lawfulness of processing based on my consent before its withdrawal. Thank you for filling out the form!
