Please complete fully and truthfully · Confidential · Data protection in accordance with GDPR
1 · Personal Details
2 · Requested Treatment
Laser Hair Removal
Laser Lifting
Microneedling
Facial Massage
Skin Treatment / Combo
Consultation
3 · General Health & Contraindications
Please tick all that apply.
Medical Conditions & States
Pregnancy / Breastfeeding
Pacemaker / Active Implants
Epilepsy
Diabetes mellitus
Coagulation disorder / Thrombosis tendency
Autoimmune disease
Active cancer or chemotherapy
Immunosuppressive therapy
Herpes (recurrent in treatment area)
Rosacea
Psoriasis / Eczema
Keloid tendency (hypertrophic scarring)
Medications
Blood thinners (e.g. Warfarin, Aspirin)
Isotretinoin / Roaccutane (acne medication)
Antibiotics (current)
Photosensitising medications
Cortisone (topical or systemic)
Hormonal preparations / Contraceptive pill
Allergies
Known allergies or intolerances? (Nickel, Latex, Cosmetics, Anaesthetics …)
No Yes →
Skin in Treatment Area (current)
Active inflammation / infections
Open wounds / injuries
Fresh tan (sun / sunbed / self-tanner)
Tattoos / Permanent make-up in area
Active acne (Grade III / IV)
Unexplained skin changes
4 · Treatment-Specific Information
Laser Hair Removal & Laser Lifting (NiSV)
Fitzpatrick skin type — please tick:
IVery light, always sunburns
IILight, usually sunburns
IIIMedium, occasionally sunburns
IVOlive, rarely sunburns
VBrown, barely sunburns
VIVery dark, never sunburns
Holiday / intensive sun exposure planned in the next 4 weeks?
No Yes
Previous laser, IPL or peel treatments in the area?
No Yes
Microneedling
Botox, fillers or hyaluronic acid in the treatment area in the last 4 weeks?
No Yes
Isotretinoin (Roaccutane) taken in the last 6 months?
No Yes
Metal implants in the face (e.g. plates, screws)?
No Yes
Facial Massages
Acute inflammation, fever or infections currently?
No Yes
Known thrombosis or suspected thrombosis?
No Yes
5 · Previous Treatments & Treatment Goal
6 · Consent & Data Protection
I confirm that all information provided is complete and truthful. I have been informed that all services offered are cosmetic in nature and do not replace medical treatment. I have been informed of possible risks, side effects and contraindications. If relevant contraindications are not disclosed, I bear full liability for any resulting damages.
I hereby give my consent to data storage in accordance with Art. 6 para. 1 lit. a and Art. 9 para. 2 lit. a GDPR. Data is stored exclusively for treatment documentation and will not be passed on to third parties. I may withdraw my consent at any time (info@portupell.com).
For laser and microneedling treatments, I confirm that I have been informed in accordance with § 3 NiSV and consent to the treatment.
Optional consent to marketing communications
I consent to PORTUPELL Skincare using my contact details (name, email, phone) in accordance with Art. 6 para. 1 lit. a GDPR to send me information about offers, promotions and news by email or phone. This consent is voluntary and may be withdrawn at any time without giving reasons (info@portupell.com). Refusal has no effect on my treatment.
Place, Date
Client's Signature
For Studio Use Only (not to be completed by client)