Client consultation form 16-18 yr olds

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

Clear
Name of parent/guardian

First Name Last Name
Date of birth of parent/guardian *

Month Day Year
Date
Signature of consent of parent/guardian

Clear

Now create your own JotForm - It's free! Create your own JotForm

Client consultation form 16-18 year olds