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 Name Last 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.

Area Code Phone Number
Date of Birth *

Day Month Year
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. *

Yes No
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. *

Yes No
The following questions are for your health & safety & are kept solely for insurance purposes.
Are you currently on any medication? *

Yes No
Please give details of medication.
Are you/could you be pregnant? *

Yes No
If pregnant, how many weeks?
Do you currently suffer, or have you ever suffered with any of the following medical conditions? *

High/Low Blood Pressure Heart Conditions Nervous System Disorders (Epilepsy/Parkinson’s/Multiple Sclerosis etc.) Circulatory Disorders Digestive Disorders Cancer Arthritis/Osteoporosis Diabetes Swelling/Oedema Asthma/Respiratory Conditions Stroke Back/Neck Problems Joint Problems Broken Bones/Fractures/Sprains Varicose Veins Allergies Hormonal/Period Problems Insomnia/Problems Sleeping Recent Operations/Scar Tissue Metal Plates or Pins Blood Conditions Migraines/Headaches Skin/Nail or Eye Conditions NO MEDICAL CONDITIONS TO REPORT
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? *

Microdermabrasion Retinol or Roaccutane Laser or IPL Treatments UV Exposure Fruit Acid Products NONE OF THE ABOVE
Patch Test Details (ignore if not applicable to you & scroll down to sign & submit your form)
Patch Test Reaction
Date of Patch Test

Day Month Year
Date
Client Signature for Patch Test

Clear
Therapist Signature for Patch Test

Clear
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 *

Clear
Date *

Day Month Year
Date
Therapist Signature

Clear
Date

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

Treatment Dates & Details (or use by the Therapist)

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