Client consultation form 16-18 year olds
A form MUST be completed before your appointment
* Name
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
* Mobile number
-
Area Code
Phone Number
Home number
-
Area Code
Phone Number
* Email
example@example.com
How can we contact you?
Call
Text
Email
In the last 14 days have you or anyone in your household
Had covid-19 symptoms?
Been around anyone with covid-19 symptoms?
Had to self isolate after being a risk of contacting covid-19?
None of the above
Medical health
Migraines
Epilepsy
Nervous system disorders
Lung or breathing problems
Heart or circulatory problems
High or low blood pressure
Kidney or bowel disorders
Bone or joint problems
Skin conditions
Cancer
Diabetes
Infections
Recent surgery
Other
Any other conditions not mentioned?
Please detail where necessary
Are you currently on any medication?
Are you pregnant or trying to become pregnant?
Yes
No
Do you have any allergies? (including food)
Date of patch test for brow or lash appointments
-
Day
-
Month
Year
Date
Treatments patch tested for
Lash tint
Brow tint
Lash extensions
Brow lamination or lash lifting
I confirm all the information given is full and correct to the best of my knowledge. I will inform Especially You Beauty Therapy therapists if here is any change to my health
I confirm
I agree to having my information stored and used for appointments and contact with Especially You Beauty Therapy
I agree
I disagree
Signature
Name of parent/guardian
First Name
Last Name
Date of birth of parent/guardian
*
-
Month
-
Day
Year
Date
Signature of consent of parent/guardian
Submit
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