Client consultation form 16-18 year olds
A form MUST be completed before your appointment
Date of birth
* Mobile number
How can we contact you?
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
Nervous system disorders
Lung or breathing problems
Heart or circulatory problems
High or low blood pressure
Kidney or bowel disorders
Bone or joint problems
Any other conditions not mentioned?
Please detail where necessary
Are you currently on any medication?
Are you pregnant or trying to become pregnant?
Do you have any allergies? (including food)
Date of patch test for brow or lash appointments
Treatments patch tested for
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 agree to having my information stored and used for appointments and contact with Especially You Beauty Therapy
Name of parent/guardian
Date of birth of parent/guardian
Signature of consent of parent/guardian
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