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Consultation Card
Prior to attending your appointment

To ensure safety for all, please complete this short questionnaire including questions about COVID-19 and your current health:

1. Have you tested positive for COVID-19, or been in contact with someone who has in the past 14 days?
2. Have you been tested for COVID-19 and are currently awaiting the test results?
3. Do you have any of the following flu like symptoms: fever, dry cough, body aches, headaches, sore throat, runny nose, shortness of breath? (Note: This refers to new or unusual symptoms not aligned with medical history. You may exclude known personal medical conditions that have the same symptoms e.g. allergies, history of migraines)
4. Are you or your immediate contacts in a high-risk category?

Please note, if you answered yes to any of the above questions, unfortunately we are unable to give you an in person treatment. Instead, we would like to offer a Mirror Me virtual service, where we can connect for a digital one to one consultation. Please cancel your current booking and rebook your Virtual Appointment on our website. 

Client Details
How did you hear about us?

Dermalogica and Orchids Retreat take privacy seriously. As the data controller of the personal data that you provide on this form, we will use your personal data for the purposes of carrying out your consultation and keeping a record of your treatments. Please refer to our full privacy policy on and for more information about your rights and how we use your personal information data. If you have any questions, please use the Contact Us function at and

I consent to Dermalogica Group and Orchids Retreat using my personal data to contact me using the methods set out below to advise me of new products, and to provide me with marketing and product information.

You can opt-out at any time by clicking on the Unsubscribe link we provide in our communications or by using the Contact Us function at and

Your Health
1. Within the last year, have you had any health problems that have affected or could affect your skin?
3. Do you wear contact lenses?
4. Do you have metal implants, a pacemaker or body piercings?
5. Do you have any allergies?
6. Do you have sinus problems?
7. Have you ever experienced claustrophobia?
Your Health
9. What skin care products are you currently using?
10. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?
11. Have you been waxed within the last 72 hours?
12. Have you shaved within the last 24 hours?
13. Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
14. Are you currently using any products that contain the following ingredients?
15. Please specify if any of the following apply to you:
16. Have you received a cosmetic light-based procedure such as laser treatment, IPL etc. within the last 6 weeks?
17. Do you have active cold sores?
18. Have you received Botox or other injectable procedures within the past week?
19. Do you sunbathe or use tanning beds?
20. Do you experience redness, itching, or stinging on your skin?
Advanced Skin Treatment Consent

This treatment is designed to resurface the skin. You may experience temporary burning, itching or stinging. Please inform your professional skin therapist if you experience these sensations.

Your full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort.

I release Dermalogica (UK) Limited and Orchids Retreat Ltd, and their respective officers, agents and employees, of and from any liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Advanced Skin Treatment, including, but not limited to, those injuries and damages caused by breach of warranty, express or implied, excluding negligence or an act or omission that directly causes personal injury, on the part of Dermalogica and/or Orchids Retreat.

Client Confirmation

Confirmation and Virtual Signature *

Thank you for submitting, we look forward to seeing you soon!

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