Client Consultation Form

Name

First NameLast Name

DOB

Address

Street Address

Street Address Line 2

CityCounty

Post code

Home phone number

Area CodePhone Number

Mobile phone number

Area CodePhone Number

Email

Occupation

How did you hear about us

Are you happy to be contacted by

PhoneEmailText

Drs Surgery

Do you have any allergies

YesNo

If you answered yes, please state what these are

Have you had any recent surgery

YesNo

Medical conditions

E.g. high blood pressure, diabetes, epilepsy

If you answered yes, please explain details of your surgery

Prescribed medication

Pregnant

YesNo

How many weeks?

Breast feeding

YesNo

What would you like to achieve from your treatment today?

Are you using any resurfacing products containing retinol/AHA’s (e.g. glycolic acid)

YesNo

Reaction to a previous beauty treatment

YesNo

If yes, please explain about the treatment

Have you had your COVID 19 vaccination?

Have you had COVID 19?

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 EYELASH EXTENSIONS prior to treatment and am happy to go ahead understanding that reactions can still occur. I will not hold the therapist/The Barn Beauty Rooms accountable if this happens we will be guided to a medical professional for assistanceI confirm I have had a patch test for EYELASH/EYEBROW TINTING prior to treatment and am happy to go ahead understanding that reactions can still occur. I will not hold the therapist/The Barn Beauty Rooms accountable if this happens and will be guided to a medical professional for assistanceI 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 Beauty 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)

Date

Any further information you feel we need to be aware of or any questions you have:

I agree not to visit the salon for any of the services provided if I have the symptoms of COVID-19.

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 Beauty 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.

Date

Signature

Name of therapist

Therapist treatment notes.

Newsletter

Yes, subscribe me to this newsletter.