Client Consultation Form
Full Name
*
First Name
Last Name
Contact Number
*
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Area Code
Phone Number
Date of Birth
*
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Day
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Month
Year
Email Address
By providing an email address you agree to sign up to our email newsletter.
Check the conditions that apply to you:
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Pregnant
Eczema
Breastfeeding
Psoriasis
Cancer
Epilepsy
Chemotherapy
Diabetes
High/Low Blood Pressure
Bruises/Varicose Veins
Recent Surgery
Circulatory Disorders
Stroke
Verrucas/Warts
Fungal Infection
Back Problems
Neck Problems
Muscular Pains
Topical Corticosteroids
None of the above
Other
What massage pressure do you prefer?
Light
Medium
Firm
Don't Know/First Massage
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any allergies?
*
Yes
No
Not Sure
Please list them.
What would you like to achieve from your treatment?
e.g. Relief from tension, Rehydrate skin etc
During your treatment we may take before and after pictures. Please specify if you are happy for these to be shared on social media and in our emails. Your therapist will always request permission before taking photos.
I am happy for my photos to be used on Beauty Revealed's social platforms and in marketing emails
I have read and understood the questions asked and can confirm that the answers I have given are correct, that I have NOT withheld any information that may be relevant to treatments
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