LEANNE'S HEALTH & BEAUTY
CLIENT CONSULTATION FORM
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Town
County
Post Code
Email
*
example@example.com
Phone Number
*
Mobile Number
*
Date of Birth
-
Day
-
Month
Year
Date
Gender
Female
Male
Undisclosed
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MEDICAL HISTORY
Do you suffer from any of the following? (please tick)
*
Allergies
Thyroid Problems
Headaches / Migraines
High Blood Pressure
Low Blood Pressure
Heart Condition
Pace Maker
Varicose Veins
Eczema/Psoriasis
IBS/Bowel Problems
Arthritis / Rheumatism
Epilepsy
Claustrophobia
Asthma / Lung Problems
Metal plates/pins
Diabetes
Muscular Pain
Anticoagulant therapy (blood thinning)
Roaccutane Treatment
Botox/Fillers
Recent Operations
Pregnancy
Chemotherapy/ radiotherapy
Cancer
Adverse reaction to essential oils
Eye disorders
Latex allergy
Cosmetic laser surgey
Back problems
Other
If you have ticked any of the above, please give details including date of vaccines:
Are you currently on any medication or under medical supervision? If yes, please give details:
Are you pregnant? Breast feeding? If yes, please give details?
Have there been any changes since your last appointment?
*
I have read and understood the questions asked and confirm that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatments. I will update my therapist with any changes. I understand the salon has a Cancellation /No Show cancellation policy and that I will be charged 50% of a missed/cancelled appointment.
*
I AGREE
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
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