Client Consultation Form

Client Consultation Form
Name
Address
Home phone number

Area codePhone Number
Mobile phone number
Email
DOB
Occupation
How did you hear about us
Are you happy to be contacted by
Drs Surgery
Are you under a physicians care for any medical conditions
If yes please state what these are
E.g. high blood pressure, diabetes, epilepsy
Do you have any allergies
If yes please states what these are
Have you had any recent surgery
If you answered yes, please explain details of your surgery and date
Please state any prescribed medication or any supplements or natural remedies
What would you like to achieve from your treatment today?
Relaxation
What is your preferred massage pressure?
Are you pregnant?
How many weeks?
Breast feeding?
Taking contraceptives
Taking hormone supplements
Reaction to a previous beauty treatment?
If yes, please explain
Skincare treatments

Please only complete for skincare treatments
Have you ever had any anti wrinkle injections, fillers, chemical peels or laser treatment?
Please state date and detail
Do you currently use or ever used hydroquinone, retin A, Accutane, isotretinoin, blood thinners. If so when?
Are you currently using benzoyl peroxide, AHA’s or BHA’s
Do you currently use or have aver used?
If so please when?
Patch testing

Please only complete for lash/brow tints, lifts or lash extensions
Patch testing. If you have not had one of the following treatments within six months you must have a patch test prior to treatment.

I confirm I have had a patch test for LVL LASH LIFTING prior to treatment and am happy to go ahead understanding that reactions can still occur. I will not hold the therapist/The Barn Treatment Rooms accountable if this happens and will be guided to a medical professional for assistance. IMPORTANT - IF YOU ARE PREGNANT OR BREAST FEEDING UP TO 6 MONTHS OR UNDER 16 YEARS OF AGE YOU CANNOT HAVE THIS TREATMENT
Date (for patch test confirmation only)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any further information you feel we need to be aware of or any questions you have:
I acknowledge that the information I have given in this form is accurate and complete. The information that you provide is kept in the strictest confidence on our database and is only used in accordance with treatments that are carried out at The Barn Treatment Rooms, White House Farm, Sprowston.

This data will be shared with the relevant therapist when required. If there are any parts of this form you do not wish to complete please contact the management via e-mail or telephone.

By signing below, I confirm that I understand and agree to all terms and statements in this form.
MonthDayYear
2 digit month, 2 digit day, 4 digit year12/08/25
Signature
Name of therapist
Therapist treatment notes.
Newsletter
Should be Empty:

Client Consultation Form

Skincare treatments

Patch testing