Zone Face Lift, Gua Sha, & Cupping

Zone Face Lift, Gua Sha & Facial Cupping

Consultation Form
Personal details

All information given remains strictly confidential. I comply with the General Data Protection Regulation, details of my privacy policy can be viewed on my website at www.kristisloanreflexology.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone number*

Area CodePhone Number
Email address
example@example.com
Date of birth*

DayMonthYear
Date
GP details*
Occupation
Ages of any children
Health Information

Caution check - Do any of the following apply to you?*

	Yes	No
Acute undiagnosed pain (refer to GP/A&E)
Allergies
Diabetes
Epilepsy
Osteoporosis
Any heart or blood pressure issues?
Varicose veins/phlebitis in treatment area
Imminent medical tests or procedures
Recent surgery
Injury or condition linked to treatment area
Cancer

If you have answered yes to any of the above, please give details:
Please note that the following are contraindicated conditions: Cellulitis in the treatment area, fever or contagious illness, deep vein thrombosis or pulmonary embolism, or clients that are currently under the influence of alcohol or drugs.
If any of the above contraindications applies to you, please give details:
Medical history
Illnesses, diseases, disorders, accidents, injuries, operations etc.
Current medications and any side effects
Recent health and lifestyle
Do you have any areas of pain at the moment?
Date of last period/how are your periods? (if applicable)
Are you pregnant, how many weeks? (if applicable)
How is your diet?
How much water or other liquids do you drink in a day? e.g. tea, coffee (caffeinated or decaffeinated?)
How is your bowel and urinary health?
Do you smoke/have you smoked in the past?
How much alcohol do you drink in a week?
How much exercise do you do and what type?
Do you find it easy to relax, and what do you do for relaxation?
How do you feel about your sleep pattern?
How would you rate your energy levels? (1 low, 10 high)
How would you rate your stress levels? (1 low, 10 high)
Any other relevant information?
Any facial skin conditions? eg. rosacea, acne, sensitivities or skin that bruises easily.
Have you had any facial surgery? Please give date and details, if applicable*
Have you had Botox or facial fillers? Please give date of last treatment, if applicable*
An interval of 3 weeks is required after Botox/Facial fillers before treating with Zone Face Lift. In some cases Facial Cupping cannot be carried out with facial fillers present, please discuss this with your practitioner.
Reason for seeking Zone Face Lift/Facial Cupping?
How did you hear about Kristi Sloan Reflexology?
Facial Cupping

Facial cupping uses gentle suction using silicone facial cups. This increases blood flow to the skin and creates a controlled mini-trauma, which prompts a natural healing process. This triggers the production of collagen and elastin.
- I understand that the suction created may cause temporary redness from the increased blood flow and stimulation and that, although not likely, it can cause bruising in sensitive skin. Arnica will be applied in such cases.
- I understand that this reaction will dissipate within a few hours to a few days.
- I understand my practitioner is trained in facial cupping and will make sure not to overwork an area to minimise any risks or marks.
- If using the protocol for Bells Palsy, Scars or Sinus conditions where my practitioner will work longer on the area concerned, using stonger suction, I understand this increases the risks of marks.
I consent to Facial Cupping. I understand the possible reactions and contra-indications and will not hold my practitioner liable if I have a reaction.

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I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive reflexology and any other therapies as listed above.
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Zone Face Lift, Gua Sha & Facial Cupping

Personal details

Health Information

Recent health and lifestyle