Client Registration Form

Specialist Cosmetic Medical & Dermal Therapy Clinic

Thank you for booking a consultation and/or treatment to see one of our cosmetic practitioners and/or dermal therapists. It is a necessary requirement of this clinic that you fill out a registration form and a comprehensive questionnaire regarding your general health and previous medical history before arriving for your consultation and/or treatment.

Please answer all questions as accurately as possible and if you have any queries regarding any of the questions please contact our friendly reception staff.

Section A: Registration

Contact Details

Please Note: A mobile phone number and email address is required for confirmation of your appointment 24-48 hours prior to the appointment time.

Methods to confirm your appointment

We can send an SMS/text message (it will come from a +614 number) with the date & time of your appointment - You can automatically reply to the text message to confirm OR cancel the scheduled appointment.

We can send an Email (it will come from Rejuven8 Cosmetix) with detailed information about your scheduled appointment - listing the individual services and times together with the name of the employee performing those services. You can automatically reply to the Email message to confirm OR cancel the scheduled appointment.

We can send you both an SMS/text message AND a detailed Email (we recommend this option). You can automatically reply to either the SMS/text message OR the Email message to confirm OR cancel the scheduled appointment.

Alternatively we can call you to confirm your appointment (Please note: We will call you if we have not received a confirmation from you via SMS/text or Email)

Methods to send reminders

We would like to send you reminders relating to the following (where relevant):

• Your pre-treatment checklist regarding the service you have booked (you will be given a link to the appropriate document)
• Your aftercare instructions relating to the treatment you have had (you will be given a link to the appropriate document)
• a reminder that a treatment you have had is now due to be repeated (e.g. when your next Botox treatment is due)

Please note these are ONLY to give you valuable information relating to a consultation and/or treatment – they WILL NOT contain promotions or marketing material.

We can send an SMS/text message (it will come from a +614 number).
We can send an Email message (it will come from Rejuven8 Cosmetix).
You can also elect to receive both an SMS/text message AND an Email message.
Alternatively we can call you directly.

Promotions, Special Discounts and Gift Vouchers

At Rejuven8 Cosmetix we would like to reward you for choosing to visit us for all your Cosmetic & Beauty Therapy needs. We would therefore like to send you promotions, special discounts and gift vouchers.

The following are examples:

• Monthly promotions that include exclusive discounts on services and/or products
• Special Occasion Gift Certificates e.g. Happy Birthday Gift Vouchers
• Gift cards to thank you for referring a friend

Please note that at Rejuven8 Cosmetix, our policy is to send these messages to you no more frequently than once per month and you can elect to change your preferences at any time.

We can send an SMS/text message (it will come from a +614 number).
We can send an Email message (it will come from Rejuven8 Cosmetix).
You can also elect to receive both an SMS/text message AND an Email message.

Client Specific

We would like to know more about your interests

Please let us know which services you are interested in: (Please tick all relevant boxes)

Section B: Consultation Questionnaire

It is important that ALL members of staff at this clinic are fully aware of any and all relevant health issues, medications and allergies in addition to any related family or past medical history. This information is vital to ensure any and all treatments you have at Rejuven8 Cosmetix are carried out safely and with minimal risk to your general health. Failure to fully inform your Cosmetic Practitioner may result in serious complications from your proposed treatment and in some circumstances these complications may be fatal.

Please answer the questions below to the best of your knowledge and as accurately as possible and if you have any queries regarding any of the questions please call the clinic to speak with one of our receptionists. All information recorded will be subject to confidentiality laws and regulations.

1. General Medical History

Read the following list of medical conditions and please check the relevant boxes that describe whether you currently suffer, have never suffered or have suffered in the past but not now, with any of the conditions listed. (Please note that if you don’t recognise the name of the conditions - you can safely assume that you don’t and never did suffer with that condition):

Do you have any of the following metallic implants?

2. Previous cosmetic/plastic surgery history

3. Previous cosmetic medical history

If yes, have you had any of the following non surgical cosmetic treatments in the past? (Please check the relevant boxes)

4. Social History

5. Medications and Natural Supplements

6. If you are female please fill out the following section

7. WHAT IS YOUR PAST EXPERIENCE WITH NON SURGICAL COSMETIC TREATMENTS

If you have had non surgical cosmetic treatments in the past, have you experienced any of the following effects from a non surgical cosmetic treatment? (Please check the relevant boxes:)

8. Skin specific questionnaire

Are you currently using any of the following preparations on your skin:

9. History of sun exposure and sun protection

SKIN QUALITY (Please check the boxes that best describe your skin and any issues you have with your skin:)

SKIN CARE ROUTINE (Please check the boxes to indicate what you are currently using as part of your skincare routine and write the name of the product where possible):

10. Fitzpatrick questionnaire to establish your skin type

Please fill out the following questionnaire by scoring your answers to the questions with the corresponding numbers (0 - 4)

SCORE:

I would like to thank you very much for filling out this form today. It will be kept in your personal file and you will be asked to review the answers to these questions annually to ensure that your records are accurate and up to date.

Rejuven8 Cosmetix Client Assurance

Rejuven8 Cosmetix is a cosmetic and dermal therapy clinic owned and operated by Dr Lindsey Hooke, a Registered Cosmetic Physician accredited by the Australasian Society of Cosmetic Medicine. Rejuven8 Cosmetix employs a combination of Medical, Cosmetic Nursing, Paramedical Aesthetic, Dermal Therapy and Beauty Therapy staff and assures clients that all staff are fully registered practitioners in their individual areas of specialty and have completed all necessary training to be fully competent in carrying out client consultations and performing cosmetic and dermal therapy treatments.

All staff performing IPL and Laser treatments are fully certified and licenced by the Queensland Department of Radiation Health & Safety in accordance with Queensland’s Radiation Health & Safety Act 1999 and the Radiation Safety Regulation 2010. Nursing staff carrying out injectable treatments are current Registered Cosmetic Nurses and have completed all necessary training being certified to use Ipsen, Allergan, Mondeal, Galderma, Sanofi-Aventis, Regen Lab, Innova, Device Technologies and Merz company products.

All Rejuven8 Cosmetix staff participate in ongoing professional development programs and undergo annual skill evaluation. As a client of Rejuven8 Cosmetix you may be required to undergo consultation and/or treatment by Medicial, Cosmetic Nursing, Paramedical Aesthetic, Dermal Therapy and/or Beauty Therapy staff. This will be clearly stated at the time of booking and if you have any questions relating to the treatment or the practitioner assigned to carry out your treatment please feel free to ask the receptionist making the booking.

For consultations and treatments to be carried out fully, it is important that clients attend promptly at the appointment time scheduled. Late arrival may result in shortening of consultation time or cancelling of treatment. Failure to attend or cancellation without 24 hours notice will incur a cancellation fee of $50.

These forms will be reviewed thoroughly by Dr Lindsey Hooke and prior to seeing your cosmetic practitioner or dermal therapist you will be asked to review the contents of this form and confirm the accuracy of your answers by signing below.

In signing this form, I acknowledge that I have read and understand its contents and that I have answered all the questions truthfully and accurately to the best of my knowledge. I understand that failing to answer these questions truthfully and accurately could lead to me experiencing a complication from any treatment carried out by staff at Rejuven8 Cosmetix. I agree to any terms stated within and verify that the information given above is accurate at the time of signing.