Client Consultation Form

The information you give here is kept securely, in the strictest confidence & is not shown or sold to any third parties.

All data is stored in compliance with GDPR regulations.

Please click here to find out more on the personal data I hold on you & why in my Privacy Policy.
Name

First NameLast Name
Address - Please only give your address if you are happy for this to be stored securely.

Street Address

Town

Post Code
Phone Number - Please only give your phone number if you consent to me contacting you in this way. I will only contact you by phone regarding any booked appointments.

CodePhone Number
Date of Birth

DayMonthYear
Date
Would you like to sign up to my mailing list to receive e-mails about special offers, treatment news & annual leave notifications? E-mails will be sent out securely via Mailchimp & you can opt out of receiving these by clicking “unsubscribe” at the bottom of each e-mail or by requesting that I remove your details from the mailing list.
Email - Please only give your e-mail address if you consent to be added to my mailing list.
example@example.com
Are you happy for me to take photos of any treatments carried out? Photos are used for the portfolio on my website & all photos are anonymous.
The following questions are for your health & safety & are kept solely for insurance purposes.
Are you currently on any medication?
Please give details of medication.
Are you/could you be pregnant?
If pregnant, how many weeks?
Do you currently suffer, or have you ever suffered with any of the following medical conditions?
Please give details of any medical conditions.
Do you have any other health conditions I need to be aware of?
Are you using any of the following skin treatments?
Patch Test Details (ignore if not applicable to you & scroll down to sign & submit your form)
Patch Test Reaction
Date of Patch Test

DayMonthYear
Date
Client Signature for Patch Test
Therapist Signature for Patch Test
I declare that the information I have given is true & correct & that, as far as I am aware, I can undertake treatment without any adverse effects.

If I feel unwell during treatment, I must notify the therapist immediately.
Client Signature
Date

DayMonthYear
Date
Therapist Signature
Date

DayMonthYear
Date
After clicking ‘Submit’ please wait for the ‘Thankyou’ Notice to appear before leaving the website.

Treatment Dates & Details (or use by the Therapist)

Should be Empty: