Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
Country
Postcode
Phone Number
*
-
Phone Number
Date of Birth
*
/
Day
/
Month
Year
Date
Please tick if you have any of the following contraindications:
Claustrophobia
Epilepsy
Diabetes
Eczema
Hypersensitive Skin
Recent Botox/Fillers
Recent Eye Surgery
Styes
Pregnancy
Conjunctivitis
Blepharitis
Wearing Contact Lenses
Reaction to patch test
Please list any physical health conditions that your therapist should be aware of (if none please write none):
Please list any medication taken regularly and any specific medication/pain killers taken today (if none please write none):
Do you have any allergies to treatments or products or sensitivities to any treatments or products?:
Date
*
-
Day
-
Month
Year
Date
Signature
*
Before Photo (Optional)
Submit
Should be Empty: