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Thank you in advance.

Please fill out form below.

Initial client form

Initial consult form

Do your have private health insurance that covers extras?
yes
no
Have you been referred by your GP or an allied health professional?
yes
no
Do you have a GP care plan?
yes
no
Current Homecare Routine: Where are you currently purchasing your skin care from?
online
Dermal/ skin clinic
pharmacy/ chemist
supermarket
Other
CURRENT AND PREVIOUS TREATMENTS: Have you received any of the following treatment(s) in the last 14 days?
Have you had surgery in the last 12 months?
Yes
No
Have you had surgery in the last 12 months?
Yes
No
Medical History: Are you currently under a physician's care for your health?
Yes
No
MEDICAL HISTORY: Do you have any of the following health conditions? (Please tick all that apply)
Are you using/ have you previously used any of the following? (Please tick):
Females Only: Are you
Trying to conceive
Pregnant
Lactating
Taking contraceptives
Are you allergic to: (Please tick all that apply)
Lifestyle
What are your current stress levels?

La Pelle Skin & Health Clinic Faith-led. Results-driven. Grounded in Science.

By signing below, I acknowledge and agree to the following:

1. Clinic Structure & Clinical Approach

I understand that La Pelle Skin & Health is a professional Allied Health skin clinic, not a beauty spa.


I recognise that my dermal treatments will be carried out by a qualified dermal clinician with a 4-year + extensive science-based degree (Bachelor of Dermal Sciences) and an evidence-based medical approach. I understand that my specialist team visits will be carried out by qualified health professionals, i.e., consultations with a dietitian (Master's in dietetics). 


I understand that La Pelle prioritises evidence-based treatments, safety, and long-term results over superficial or one-off treatments.


2. First Visit & Consultation

I understand that treatments may not always be performed during my first visit, as this time is reserved for consultation, skin analysis, education, and patch testing (if required).


I understand the purpose of the initial consultation is to ensure safety, assess suitability for treatment, and create a personalised plan. 


If I have booked an initial consultation with an added skin prep treatment, our clinician may refuse if they feel it is not suitable or if prepping with home care and other treatments may be needed prior to commencing. Please understand that this treatment consists of foundational treatments such as LED, infusion, or superficial chemical peels to prepare for the journey ahead. More advanced dermal procedures will not be performed during this visit. 


3. Treatment Programs & Membership Structure

I understand that La Pelle has designed programs and memberships to promote consistency, commitment, and the best outcomes.


While pay-as-you-go is available, I acknowledge that results may be limited without consistent attendance or adherence to the treatment plan.


I understand that pre-booking appointments is part of the treatment strategy to ensure correct clinical timing and outcome delivery.


4. Pricing & Payment

I confirm that I have reviewed the clinic’s current pricing and understand that pricing may change based on product or supplier costs.


I understand that full payment is required before treatment.


If I am on a treatment package, I agree to pay 50% before the first session and the remaining balance before the second session, regardless of any rescheduling.


I understand that late payments may incur a $50 fee per month unless prior arrangements are made.


5. Cancellation, Refund & Product Policy

I agree to provide 48 hours' notice for cancellations or changes. I understand that failure to do so may result in the full service being charged or deducted from my plan.


I understand that all product and service purchases are final. No refunds or exchanges will be provided for a change of mind.


6. Aftercare & Homecare

I understand that following the recommended home care and post-treatment protocols is crucial for achieving optimal results and ensuring safety.


I agree to use only the recommended products that have been provided or approved by my clinician.


I will avoid picking, scratching, or exposing my skin to the sun without SPF 50+ protection.


7. Medical & Safety Disclosures

I confirm that I have disclosed all relevant medical conditions, medications, allergies, and any changes to my health.


I understand that a medical clearance may be required before certain treatments and that skin cancer checks are encouraged before starting some procedures.


8. Treatment Expectations & Results

I understand that results are not guaranteed and depend on various factors, including age, health, lifestyle, skin condition, and adherence to the treatment plan.


I acknowledge that multiple treatments may be required to achieve desired results, and outcomes may vary.


I understand that short-term side effects, such as redness, dryness, breakouts, flaking, or changes in pigmentation, may occur and are part of the normal healing process.

By signing below, I acknowledge and agree to the following:Financial Responsibility & Payment Obligations

Our Commitment to Accessible Care: At La Pelle Skin & Health, we recognise that financial wellness is an integral part of your overall health and well-being. We are committed to providing accessible and affordable care, and we encourage open communication about your financial circumstances at any time.


Payment Agreements: I understand that financial commitments made for treatments, payment plans, or memberships are binding agreements that provide structure for both my care and the clinic's operations.


I agree to honour payment obligations according to our agreed schedule, understanding that consistent payments allow the clinic to maintain high-quality services and fair pricing for all clients.


I understand that payment due dates provide important structure for treatment planning and that appointment changes do not automatically extend payment timelines.


Third-Party Payment Services: I acknowledge that by using services like Afterpay or PayPal, I agree to their terms in addition to La Pelle's policies.


Communication & Support: I'm encouraged to communicate openly with La Pelle if my financial circumstances change or if I'm experiencing difficulty meeting payment obligations. 


The clinic recognises that life circumstances can change, and early communication allows us to explore options together.

I understand that while the clinic maintains policies around refunds and payment commitments, they are committed to working within my budget and means to find suitable repayment solutions when possible.


I agree that financial discussions will be part of my regular consultations, ensuring that my treatment plan remains comfortable and sustainable for my circumstances.


Account Management: I understand that late payments may result in administrative fees, and that continued payment difficulties may affect my ability to receive services until the issue is resolved.


I acknowledge that I am responsible for costs associated with account management, including any administrative fees for payment processing.

I understand that outstanding balances may accrue interest charges and that any collection-related expenses will be added to my account.


Service Continuity: I understand that while La Pelle strives to accommodate financial challenges, failure to communicate or resolve payment issues may result in the temporary suspension of services to protect both parties.


I acknowledge that during account resolution periods, no refunds will be provided for unused treatment portions, but the clinic will work to find alternative solutions where possible.


Ongoing Partnership: I understand that payment arrangements or extensions are acts of goodwill that do not eliminate my financial obligations but demonstrate the clinic's commitment to supporting my health journey.


I agree to maintain current contact information and engage honestly in financial discussions to ensure the best possible care without compromising my financial well-being.


Our Promise: La Pelle is committed to ensuring that financial circumstances never prevent you from receiving the care you need. We encourage honest and ongoing conversations about your budget and will always strive to find solutions that work for both your health goals and your financial reality.

Refund Policy Understanding: I have read and understand the refund and cancellation policy as detailed in La Pelle Skin & Health Clinic's Terms and Conditions (www.lapelleskinhealthclinic.com.au/terms-and-conditions).

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