Roman Beauty Salon Consultation Form
Please fill out this form so it is returned to us at least 24 hours before your appointment. Your information will be used to determine whether it is safe for you to have a treatment and will also be used to help us tailor-make your treatments in order to give you the best results. Your information is held privately and securely by Roman Beauty Salon, for Roman Beauty staff access only. We never share your information with third parties.
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Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth:
e.g: 05/01/1981
Occupation
Doctors Name & Address
Doctors Telephone Number
Any known medical conditions / Ailments/ Health Problems? (please select the ones which apply to you)
Diabetes
Epilepsy
Heart Condition
High Blood Pressure
Low Blood Pressure
Kidney Related Problems
Liver Related Problems
Major Operations in the last 12 months / Scar Tissue
Hormone Irregularities
Heat Sensitivity
Headaches / Migraines
Asthma
Circulatory Disorders / Varicose Veins
Thrombosis / Embolism
Skin Disorder / Infection / Cold Sores / Warts / Verrucas
HRT
Nail Disorders or Infections
Arthritis
Chilblains / Athletes Foot
Ear Infection / Grommets / Perforated Eardrum
Eye Infection / Stye / Conjunctivitis
Bruising / Swelling / Cuts or Abrasions
Injuries / Recent Fractures / Sprains
Other
If You Have Selected Any Of The Above, Please Include Full Details/ Area Of The Body Here;
Have you had your 1st COVID-19 Vaccine? (Please note: If you have had a vaccine you will need a new patch test a minimum of 24 hours prior to any Brow Tint, Lash Tint, or Lash Lift Appointments)
Yes
No
If you answered YES, please let us know the date you had your 1st vaccine
Have you had your 2nd COVID-19 Vaccine? (Please note: If you have had a vaccine you will need a new patch test a minimum of 24 hours prior to any Brow Tint, Lash Tint, or Lash Lift Appointments)
Yes
No
If you answered YES, please let us know the date you had your 2nd vaccine
Have you ever had a positive COVID-19 Test? (Please note: If you have had a positive COVID- 19 test, you will need a new patch test a minimum of 24 hours prior to any Brow Tint, Lash Tint, or Lash Lift Appointments)
Yes
No
If you answered YES, please let us know how long its been since you fully recovered from any symptoms
Any Known Allergies / Sensitive Skin?
Are You Taking Any Medication? Please List Below.
Are You Taking Any Medication Or Using Any Products That Thin The Skin?
Yes
No
Are You Pregnant? (Important: If you tick 'NO' but become pregnant at a later date, you must inform us prior to attending any future appointments, as some treatments may be deemed unsafe whilst pregnant, or if you have a history of miscarriages. In this instant you may need approval from your Doctor before a treatment can go ahead.)
Yes
No
If You ticked YES, How Many Weeks?
Are You Breast Feeding?
Yes
No
Indemnity
I declare that the information I have given is correct. I understand that the information above is needed by Roman Beauty Salon, to ensure the best possible service and my own safety whilst receiving treatments. I take full responsibility to inform Roman Beauty Salon of any changes to the above information, in advance of, and prior to ALL future appointments. I also understand there is a strict cancellation policy in place and I accept the terms that I am required to give 24 hours notice to cancel or reschedule an appointment, to avoid such fees listed in my appointment confirmation email. I am happy to proceed with treatments, and take full responsibility to follow any aftercare advice provided by my therapist, to ensure the best results from my treatment..
Signature
Date
-
Month
-
Day
Year
Date
Thank You for completing your consultation form! We will be in touch if we require any further information based on the details you have provided. We look forward to seeing you at your appointment!
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