New Client | Hannah Aesthetics

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Name(Required)

First Last Preferred Name

Gender(Required)

Male

Female

Other

Date of Birth(Required)

DD slash MM slash YYYY

Occupation

Email Address(Required)

Enter Email Confirm Email

Mobile Number(Required)

Home Number

Address(Required)

Address City/Suburb State Post Code Country

Emergency Contact Name(Required)

Relationship to you(Required)

Contact phone number(Required)

I agree to receive communication from the team at Hannah Aesthetics(Required)

Yes

How did you hear about us?

If you have been referred to us by a friend or a team member. Please tell us who it was so we can say thank you.

Please identify your main cosmetic concern/s

PREVIOUS COSMETIC PROCEDURES – If you have had any cosmetic procedures previously, please list them below

PREVIOUS FACIAL SURGERY – If you have had any previous facial surgery, please list the procedures and dates of the procedures below.

Are you interested in any other cosmetic treatment at Hannah Aesthetics? Please click the checkbox to any that apply.

Anti-wrinkle injections

Dermal fillers – lips, cheeks etc.

Microdermabrasion/Hydrabrasion

Facials

Coolsculpting fat reduction

Acne treatments

Skin resurfacing treatments

Skin tightening treatments

Medical grade skin care

Pigmentation and vascular treatments

Hair removal

Skin needling

ALLERGIES – If you have any known allergies, please list them below.

If the answer is NO, please leave blank.

MEDICAL CONDITIONS – If you have any diagnosed medical conditions, please list them below

If the answer is NO, please leave blank.

MEDICATIONS AND HERBAL SUPPLEMENTS – If you are taking any regular medications or herbal supplements, please list them below.

If the answer is NO, please leave blank.

FAMILY MEDICAL HISTORY - If you have any medical history that runs in your family, please list below.

Are you a smoker?

Yes

Do you drink alcohol? If yes, how many on average per week?

Are you pregnant, breastfeeding, or planning to fall pregnant in the next 3 months?

Yes

Possibly

If your skin is exposed to the sun for one hour with no protection, which category best describes your skin’s reaction?

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, sometimes tans

Always tans

Asian, Hispanic, Mediterranean, Middle Eastern

Black

Are you currently using any of the following skin care products?

Vitamin A

AHA - Alpha Hydroxy Acids

Hydroquinone

Other Skin Lightening Products

Are you prone to keloid or hypertrophic scarring after an injury?

Yes

Hannah Aesthetics Cancellation Policy - We understand that life can throw a curveball at the last minute and this can be unavoidable. However if you need to cancel an appointment within 24 hours due to circumstances that are within your control, we do ask that you agree to our cancellation policy that helps to ensure valuable appointment times are made available to other clients. If an appointment is not cancelled 24 hours in advance, a $50 fee will be applied to your account. Thank you for your understanding.(Required)

Yes

By pressing SUBMIT, you are confirming that all information is true and accurate at time of completion. Thank you, we are looking forward to seeing you soon.

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