Client consultation form

Client consultation form

A form MUST be completed before your appointment
* Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
* Mobile number*

Area CodePhone Number
Home number

Area CodePhone Number
* Email*
example@example.com
How can we contact you?

CallTextEmail
In the last 14 days have you or anyone in your household

Had covid-19 symptoms?Been around anyone with covid-19 symptoms?Had to self isolate after being a risk of contacting covid-19?None of the above
Medical health

MigrainesEpilepsyNervous system disordersLung or breathing problemsHeart or circulatory problemsHigh or low blood pressureKidney or bowel disordersBone or joint problemsSkin conditionsCancerDiabetesInfectionsRecent surgeryOther
Any other conditions not mentioned?
Please detail where necessary
Are you currently on any medication?
Are you pregnant or trying to become pregnant?

YesNo
Do you have any allergies? (including food)
Date of patch test for brow or lash appointments

DayMonthYear
Date
Treatments patch tested for

Lash tintBrow tintLash extensionsBrow lamination or lash lifting
I confirm all the information given is full and correct to the best of my knowledge. I will inform Especially You Beauty Therapy therapists if here is any change to my health*

I confirm
I agree to having my information stored and used for appointments and contact with Especially You Beauty Therapy*

I agreeI disagree
Signature*

Clear