Consent & Health Screening

Skin Treatment Consent

For microneedling, exosomes, chemical peels and the Oxy Facial. Please complete this before your appointment so we can check the treatment is right for your skin.

How your information is used. Evergreen Essence collects these details only to assess whether a treatment is safe and suitable for you, and to keep a record of your care. They are not sold or shared, and are kept only as long as needed. To see, correct or delete your information, email evergreenessencespa@gmail.com.

About you

 Step 1
Street, city and postal code.

Which treatment

 Step 2

Tick everything you're booking. We'll screen for all of them.

Health screening

 Step 3

Answering yes does not automatically rule you out. It tells us what to check, adjust, or get clearance for.

  • Are you pregnant, breastfeeding, or trying to conceive?
  • Have you taken Accutane / isotretinoin in the last 12 months?
  • Have you ever had a keloid or raised, thickened scar?
  • Do you get cold sores (herpes simplex)?
  • Do you currently have active, inflamed or cystic acne?
  • Do you have any active skin infection, open wound, or rash in the treatment area?
  • Are you taking blood thinners, or do you have a bleeding or clotting disorder?
  • Do you have an autoimmune condition, or are you immunosuppressed?
  • Do you have eczema, psoriasis, rosacea or dermatitis in the area?
  • Have you been sunburnt, or used a sunbed or fake tan, in the last 2 weeks?
  • Have you had waxing, laser, dermaplaning or another peel in the last 7 days?
  • Are you using retinol, tretinoin, or exfoliating acids (AHA / BHA)?
  • Have you had Botox or dermal filler in the area in the last 2 weeks?
  • Are you currently having treatment for cancer, or have you in the last 12 months?
  • Do you have diabetes?
  • Do you have any allergies — including latex, topical anaesthetic, or nickel?

Anything else we should know

 Step 4
Please list anything you answered yes to above, plus your current skincare routine.

What I understand

 Step 5

Your signature

 Final step
By typing your full legal name below you are signing this form electronically. This carries the same weight as a handwritten signature.

A copy goes straight to Evergreen Essence. Nothing is shown publicly.

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