Client Consultation Form for Elemis Treatments
Please fill this form in and return it to PURE at least 24hrs before your appointment. It is important for us to know your information and medical history prior to your visit to assure you we will be carrying out the best appropriate treatment. ALL questions must be answered for insurance purposes.
Name
First Name
Last Name
Email Address:
Address:
Street Address
Street Address Line 2
Town
County
Postcode
Mobile Number:
-
Date of Birth
-
Month
-
Day
Year
Date
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Medical Information
Doctors Name
*
Doctors Surgery & Address:
Do you suffer from any of the following medical conditions:
Allergies
Asthma
Arthritis
Back problems
Chemotherapy/radiotherapy
Claustrophobia
Constipation
Diabetes
Eczema
Epilepsy
High/low blood pressure
Hyperthyroid
Heart condition
IBS
Iodine allergy
Multiple sclerosis
Pacemaker
Psoriasis
Rheumatism
Thrombosis/Phlebitis
Tumours
Skin infections
Eye infections
AIDS/HIV
Varicose Veins
Other
Medical History
Are you on any medication or under any medical supervision?
Have you had any recent surgery, accidents or injuries?
Have you any facial implants?
Have you had any Botox/dermal fillets/facial peels/AHA’s.
Other
If you have ticked “yes” in any boxes above, please put further information below:
Are you going through any of the following medical conditions
Breast feeding
Headaches/migraines
IVF
Menopause
PMT
Pregnancy
Other
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If you are having an Elemis treatment please complete the following
If you are not having an Elemis treatment, please proceed to the next section...
Lifestyle Consultation
Please fill in the following information to give your Therapist a view of your needs and concerns.
How to you rate your stress levels
Low
Manageable
High
Through the roof!
What is your quality of sleep?
Broken
Light
Deep
How often do you exercise?
More than once a week
Weekly
Very occasionally
Never
Do you smoke?
Yes
No
Do you travel abroad more than twice a year?
No
Yes, quarterly
Yes, monthly
Yes weekly
Do you wear contact lenses?
No
Yes
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DIET
How would you describe your diet?
Balanced
Moderate
On the run
Poor
How many units of water do you consume a day?
(Units being 125ml)
How many cups of coffee do you consume a day?
How many units of alcohol do you consume a week?
(Units being 125ml)
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SKIN TYPE AND CONCERNS
Fill in this section if you are having a facial treatment. If you are having a body treatment, please go to the next section.
Is this your first facial
Yes
No
How would you describe your skin?
Normal
Dry
Combination
Oily
Sensitive
What are your main skin concerns
Blemishes
Combination/Oily
Dry/Dehydrated
Dull Skin/lack of radiance
Fine Lines & wrinkles
Lifting & firming
Pigmentation/uneven skin tone
Puffiness/dark circles
Sensitive
Smoothing/resurfacing
What is your current skin care routine:
Eye make-up remover
Cleanse
Tone
Moisturise
Exfoliate
Serum
Neck treatment
Eye treatment
Other
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Please answer this section if you are having a Massage or Body Wrap
What is your bodycare routine
Dry Body Brushing
Body Scrub
Shower Wash
Bath Oil
Body Cream
Cellulite treatment
Body Oil
Hand Cream
Foot Cream
Self Tan
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TINTING/LASH TREATMENTS
You are required to have a skin patch test for Lash Extensions, LVL Lashes and any tinting treatments. This test must be carried out at least 24hrs before your treatment. Please can you confirm you have had this patch test and had no adverse reactions by ticking the box below for the appropriate test you have had. You relinquish your Therapist and PURE of any adverse reactions you may have.
I have had a skin test for:
LVL Lashes
Lash Extensions
Brow & Lash tinting
Please note: you will need a new skin test if you havent had a treatment for over 6 months.
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DECLARATION
I confirm that the information given above is correct to the best of my knowledge. I am happy to undertake treatment at PURE. If there is any change to any of the above circumstances I will inform my Therapist at the earliest opportunity and I understand there will be no liability on the Therapist’s part should I fail to do so.
By ticking the box below, you are agreeing to the above declaration:
Tick here
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: